Question

Surgery was uneventful and the patient is taken to PACU. Upon arrival to PACU, vital signs are 98/68, 101, 16, 97.2oF. He briefly arouses to stimulation. Oxygen is being administered at 4L/NC, and LR infuses well at 100 mL/hr. His indwelling catheter is patent with approximately 50 mL dark yellow urine. The Hemovac drain to the left hip is compressed with a small amount dark red drainage. His dressing site is dry and intact. At 45 minutes into the PACU stay, the patient’s vital sign are 90/58, 115, 10, 97oF, he moans with tactile stimulation, the urine amount remains about 50 mL, the Hemovac drain has approximately 200 mL dark red drainage, and his dressing is ½ saturated with dark sanguinous exudate. Dark purple bruising is evident to the left thigh.

What complications is this patient experiencing?

What interventions should the nurse implement?

Answer 1

1. Hemorrhage, : Here the patient hypotension (90/58mm of hg, tachycardia 115, bradypnea 10 urine output is 50ml, dressing saturated with dark sanguinous exudates and hemovac drain 200ml these all are the symptoms of hemorrhage. It is major complication after surger.
2. Intervention

• Assess the severity of bleeding
• Identify source of bleeding.
• Closely monitoring vital signs
• Check renal profile and INR
• Immediate diate volume resuscitation by intravenous fluids normal saline or ringer lactate.
• Blood and blood products transfusion prn
• Stop anticoagulant if administered.
• Sterile clinical examination
• Administer tranexamic acid as prescribed by the physician.