The Patient Returning to the Surgical Floor after Surgery
Recap: Mara, a 58-year-old lady from First Nations, having an open cholecystectomy under
general anesthesia. She has had diabetes since she was 28 years old.
She had a light breakfast at 0600, and a glass of apple juice at 1000. It is now 1300 on the day of
surgery.
1600:
Mara returns from her surgery, after having an open cholecystectomy. The report from the
Recovery Room nurse includes the following: BP is 98/62, 68/min regular, T 36.9C, RR 12/min,
and SaO2 91%. Last glucometer an hour ago was 8.2 mmol/L. Her abdominal dressing has a 4 x
4 “ bright red spot on the outside of the bandage. She expresses pain as a 3/10, surgical site
area, as a pain that is constant, and does not radiate. She feels nauseous. She opens her eyes as
you speak with her, but then falls back asleep. IV R/L at 125cc/hr via RPIV. She has a Foley insitu
draining clear yellow urine.
1. The recovery room nurse and a nurse from your unit assist in transferring the patient from
the stretcher to her bed. What should be included in your initial assessment?
2. What interventions will be provided?
3. What assessments should be included in your secondary assessment?
At 1630, with her repeat vital signs, the nurse notes her vital signs are 88/62, 88/min, 12/min,
and SaO2 is 91%.
4. What else should be assessed? What should the nurse be considering at this time?
With Mara’s next set of vital signs, the BP is 102/68, 72/min, 14/min, and SaO2 is 94%.
5. What interventions led to the change in vital signs?
At 1730, the nurse notes large sanguineous drainage on the abdominal dressing Some has
leaked onto the blue pad under the patient.
6. What are the next steps for the nurse and the rationale for each?
7. Identify the interventions the nurse will implement to reduce the risk of complications post
operatively. Indicate the intervention and the rationale.