Gastrointestinal System Disorders Q 167 - Gyan Darpan : Learning Portal
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Wednesday, 13 April 2022

Gastrointestinal System Disorders Q 167

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
    A. Notify the physician.
    B. Document the findings.
    C. Irrigate the T-tube.
    D. Clamp the T-tube.

Correct Answer: B. Document the findings.

Following cholecystectomy, drainage from the T-tube is initially bloody and then turns green-brown. Fresh post-op (1-2 days): drainage starts out with some blood and then progresses to a greenish/yellow/brown liquid drainage. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml per day. The nurse would document the output.

Option A: Notifying the physician is unnecessary. The fluid may appear bloody for the first day or 2. The color will eventually be golden yellow or greenish, depending on exactly where the catheter is inside the body. There will be bile (yellow-green fluid) flowing into the bag.
Option C: There is no need to irrigate the T-tube. The client will need to flush the catheter with normal saline twice a day. If the doctor instructed to flush with less than 10 mL, squirt the extra saline out before connecting the syringe. Push the plunger of the syringe to push 1/3 of the normal saline into the catheter, and then pause. Push in another 1/3 of the normal saline, and pause again. Push in the rest of the normal saline into the catheter.
Option D: The doctor may order the t-tube to be clamped at times so bile can drain to the duodenum so fats can be digested during meal times. Assess how well the patient tolerated the t-tube being clamped. If a patient develops abdominal pain, nausea, vomiting, etc. unclamp it and notify the physician.

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