The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?
A. Clamp the T-tube
B. Irrigate the T-tube
C. Notify the physician
D. Document the findings
Correct Answer: D. Document the findings.
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. 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.
Option A: 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. If choledocholithiasis persists, the T-tube can be clamped to promote stone passage. If signs or symptoms of cholangitis occur, the tube can be unclamped and repeat imaging is obtained.
Option B: 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. Never pull back on the plunger.
Option C: Notify the physician if the drainage is more than 500 mL/day. Watch for extremely thick, bad-smelling drainage with a fever or extremely bloody like bright red blood that looks fresh. Assess how well the patient tolerated the t-tube being clamped. If the patient develops abdominal pain, nausea, vomiting, etc. unclamp it and notify the physician.
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