d.
Nursing Implications for the Early Detection of Pending Hypovolemic
Shock.
(1)
Inspect the surgical dressing and report bleeding to the Charge
Nurse.
(2)
If the patient has a large dressing in place, always check under the
patient because the blood may drain down the sides and pool under the patient. There
may be no evidence of bleeding on the top of the dressing.
(3)
Reinforce the original dressing after indicating outline of blood
perimeter stain on original dressing.
(4)
Report to the Charge Nurse the color and amount of blood. Bright
red blood indicates fresh bleeding; brownish blood indicates bleeding that is not fresh.
(5)
Record all of the above events in the Nursing Notes.
(6)
Monitor vital signs as ordered and report:
(a)
Fall in blood pressure.
(b)
Rapid, weak pulse.
(c)
Restlessness.
(d)
Cool, moist skin.
(7)
Administer narcotics only after checking doctor's orders and
consulting with the Charge Nurse. Narcotics may precipitate shock in patients in whom
shock is imminent.
(8)
Administer fluids to replace volume as ordered by the physician.
Fluids include whole blood products, plasma expanders, and IV fluids.
3-5.
GENERAL NURSING IMPLICATIONS FOR THE CARE OF A PATIENT
Nursing interventions immediately after surgery are carried out by the recovery
room nurses. These nurses have special skills to care for a patient recovering from
anesthesia and surgery. Their main goals are to make sure the patient is comfortable
and safe while in the recovery room. The nurses will:
a.
Maintain proper functioning of drains, tubes, and intravenous fluids.
MD0915
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