A client who underwent abdominal surgery earlier in the day has a small amount of bright red blood on the surgical dressing. How should the nurse document this type of wound drainage?

1. A

   Serosanguineous

2. B

   Purulent

3. C

   Sanguineous

4. D

   Catarrhal

Appeared in: NORCET 5 Prelims - Sept 2023 (Shift-1)

Explanation

Listen in Hindi

• Sanguineous drainage is the medical term for fresh bleeding, characterized by its bright red color.
• This type of drainage is composed mainly of red blood cells and is expected in small amounts immediately following surgery or significant tissue injury.
• The presence of bright red blood on the dressing aligns directly with the definition of sanguineous exudate.

Why Other Options Were Wrong

• Option A: Serosanguineous drainage is a mixture of blood and serous fluid, which gives it a pale pink or light red, watery appearance. The question describes 'bright red blood', not pink and watery drainage.
• Option B: Purulent drainage is thick, varies in color (yellow, green, brown), and often has a foul odor. It is a sign of infection.
• Option D: Catarrhal exudate is related to the inflammation of mucous membranes, such as in the respiratory tract during a cold. It consists of mucus and is not a type of drainage from a surgical wound on the abdomen.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Identification and documentation of wound drainage types to guide bedside assessment, documentation, and the next nursing action.
• Accurate assessment and documentation of wound drainage are fundamental nursing responsibilities. It allows the healthcare team to monitor wound healing, identify early signs of complications, and intervene promptly.
• A change in the type or amount of drainage is a critical finding. For example, a sudden increase in sanguineous drainage could indicate hemorrhage, requiring immediate notification of the surgeon.
• What if? If the nurse observed a large amount of sanguineous drainage saturating the dressing, the priority action would be to apply direct pressure, assess the patient's vital signs for signs of shock (hypotension, tachycardia), and notify the surgeon immediately, as this could indicate active hemorrhage.

How to Approach the Question

• First, identify the key information in the question stem: 'small amount of bright red blood' on a surgical dressing 'earlier in the day' after surgery.
• Analyze the keywords. 'Bright red blood' is the most critical descriptor of the drainage.
• Review the options and match the description to the correct medical terminology. Recall or look up the definitions for each type of wound drainage.
• Sanguineous directly translates to bloody. 'Bright red' indicates it is fresh blood.
• Eliminate the other options. Serosanguineous is pink/watery. Purulent is a sign of infection (pus). Catarrhal relates to mucus membranes, not surgical wounds.
• Confirm that sanguineous drainage is an expected finding in small amounts immediately post-surgery, which fits the scenario.

Concept Tested & Keywords

• Concept Tested: Identification and documentation of wound drainage types.
• Stem keywords: abdominal surgery, bright red blood, surgical dressing, wound drainage
• Lead-in keywords: How should the nurse document
• Clinical cues: The drainage is described as 'bright red blood', which is the key descriptor.
• Clinical cues: The timing is 'earlier in the day' after surgery, which is the immediate postoperative period.

Question ID

QW0FSzkvkTU6TAvKoJKWMi

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 6 pp. 81-83, 196-198

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 122-124