Question

A 25-year old client returned from surgery 6 hours ago for an appendectomy. She is getting out of bed to ambulate for the first time and complains of severe dizziness and feels very clammy. As her nurse what do you do next?

Answer 1

Feeling severe dizziness and feels very clammy is an indication for post operative internal bleeding after appendectomy. The nurse should be more vigilant and careful in this situation.

> Help the patient to lie down to bed immediately

>Moniter the vital signs including systolic and diastolic blood pressure,assess the central and peripheral pulse, and heart rate. Check for the capillary refill and observe nail bed and mucous membrane

>Assess the ECG for dyrhythmias

>Moniter the oxygen saturation and arterial blood gases

> Ensure the patency of the airway

>Check the neurological status of the patient as he is oriented to time,place,and person

> Assess the wound site for any active bleeding or signs and symptoms of peritonitis

> Inform the responsible surgeon as it is the clear signs and symptoms of internal bleeding

Bleeding within the first 24 hour of surgery it is called Reactive bleeding, if it is not diagnosed and treated earlier patient will go to hypovolemic shock which is dangerous.