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A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. the client is receiving oxygen and an intravenous infusion. within the first hour, the client has 50 ml of sanguineous drainage in the portable wound drainage system. which initial action should the nurse take?

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danilosanmartin
Before anything else, vital signs of the patient should be checked and any derangements should be relayed to the attending physician. The nurse should drain 50 mL of sanguineous drainage (meaning it is bloody) and record it in the chart. 50 mL of blood loss within the first hour post-operatively is considered normal since clotting mechanisms inside the surgical site is not yet fully activated. The nurse should inform the attending physician of the findings.

The nurse should note all the vital signs and report it.  

The sanguineous drainage or the bloody drainage is normal in the first few hours of the surgery and drainage up to 50 milliliters are generally observed in such case. The bloody drainage is caused because of the dissection and the clotting mechanism is not still activated in that particular region. So, the nurse should record all the vital signs of the patient and report it to the physician.  


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