The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate?
A. Notify the physician.
B. Continue to monitor the drainage.
C. Document the finding.
D. Mark the drainage on the dressing and monitor for any increase in bleeding.
Correct Answer: A. Notify the physician.
If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicated hemorrhage. Enucleation is the removal of the eye from the orbit and involves the separation of all tissue connections between the globe and the orbit. The main indications for enucleation are trauma, painful eye, a blind eye, which is unsightly, intraocular malignancy, and as part of eye donation.
Option B: Postoperative orbital hemorrhage after enucleation is rare with the use of compression bandages, and the precautions discussed earlier. If severe hemorrhage occurs, surgical exploration may be necessary, and separate incisions can decrease wound dehiscence and fat atrophy.
Option C: This is not a normal finding. Edema of the orbit after enucleation is common and usually settles down with time. Orbital infection is a rare complication but can lead to wound dehiscence, implant exposure, and extrusion. Symptoms can be increased chemosis and persistent pain in the socket.
Option D: The pressure patch can remain in place up to a week to reduce postoperative edema, although it is generally removed in 24 hours because of the inevitable oozing and soaking of the dressing that occurs. It will need to be removed to allow the application of topical antibiotics and corticosteroid ointment onto the conformer.
No comments:
Post a Comment