The nurse is assessing a male client 24 hours following a cholecystectomy.
The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?- A- Clamp the T tube
- B- Irrigate the T tube
- C- Notify the physician
-
D- Document the findings
the most appropriate intervention in this scenario is: C. Notify the physician.
Here's why:
- Clamping the T-tube (A):
This action could disrupt the drainage process and potentially lead to bile collection and complications.
- Irrigating the T-tube (B):
While irrigation may be part of the care plan in some cases, it should only be done under the physician's specific instructions and with proper sterile technique.
- Documenting the findings (D):
While documentation is crucial, it is not the immediate action required in this situation.
Green-brown drainage:
The green-brown drainage, especially in such a large volume (750 mL) within 24 hours after surgery, could be a sign of:
- Excessive bleeding:
This can occur due to complications during surgery or issues with blood clotting.
- Infection:
Bile can turn green-brown due to the presence of white blood cells fighting an infection.
- Liver dysfunction:
In some cases, altered liver function can affect the color and composition of bile.
Therefore, it is crucial to notify the physician immediately to assess the situation and determine the appropriate course of action. They may order additional tests, adjust medications, or intervene with further treatment as needed.
