PostOp Hemorrhage

PostOp Hemorrhage

Clinical Findings

Neuro: Early signs: anxiety, agitation, restlessness, lightheadedness; late signs: decreased LOC, confusion. Resp: Shortness of breath, respiratory distress. CV: Hypotension (late sign), tachycardia, capillary refill _3 seconds, diminished peripheral pulses. Skin: Cool, pale, diaphoretic, cyanosis, mottled, ecchymosis. GI/GU: Rigid, distended abdomen; periumbilical and/or retroperitoneal bruising; nausea, hematemesis; decreased UO, thirst. MS:Weakness, fatigue. Incision: Excessive swelling and ecchymosis. Other: Excessive wound drainage, saturated dressing, melena, excessive blood loss via chest tube or NGT.

Nursing Interventions

■ Assess for and control external bleeding with direct pressure. ■ Get help and notify surgeon STAT. ■ Discontinue any thrombolytics or anticoagulants. ■ Reinforce saturated dressing with additional dressing and pressure (do not remove saturated dressing). ■ Lay Pt flat, unless contraindicated by respiratory or airway compromise, and elevate the foot of the bed 10–15 degrees. ■ Anticipate and prepare for Pt to return to surgery. ■ Assess LOC and orientation. ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain and record outputs (surgical drains, urinary catheter). ■ Obtain type and crossmatch status from blood bank. ■ Administer IV fluids and assist with administration of blood products if ordered. ■ Consult surgeon about continued treatment, including STAT labs (Hgb and Hct, type and crossmatch, ABGs, electrolytes, coagulation studies), volume expansion, portable chest or abdominal x-ray, and return to surgery. ■ Document assessments, any interventions, and outcome.