Nursing diagnosis in relation to chemical-Gal, stagnation of secretions, altered nutritional status (obesity) and metabolic status, physical disturbance of the structure of the T-tube or flat cut
It is obvious from
Interruption of the skin or subcutaneous tissue
Desired outcomes / evaluation criteria, the client
Healing: primary and secondary
Rankings rapid healing without complications.
Demonstrates behaviors promote healing and prevent skin damage.
Nursing interventions on the ground:
The first track of color and type of PG and T-tube drainage.
Background: At first, draining the blood and bloody fluid that the usually green-brown (color liter) after the first few hours.
Support for second T-tube closed collection system.
Background: To avoid skin irritation and reduce the risk of infection.
3rd Watch T-tube drainage incision, make sure they are plastic.
Background: T-tube can remain in the duct for 7 to 10 days to remove retained stones and pebbles. Cut channels for the removal of accumulated fluid and bile. Proper placement, the backup of bile in the operative field.
The fourth main sewer lines, pipelines and sufficient to the hand and avoiding knots and twists release.
Reason: no release tube and lumen closure.
5th Change towels often in the first instance, it is necessary. Close the skin with soap and water. Use sterile gauze petroleum jelly, zinc oxide, powder or gum around the cut.
Reason: Keep the skin around the incision clean and providing a barrier on the skin from peeling T-tube bile leak.
Application of Montgomery sixth tapes for customers who open cholecystectomy.
Background: facilitating regular dressing changes and reduction in skin injury.
Use bags of one hundred seventh mA drain stab wound.
Justification: stoma appliance can be used for drainage difficult to accurately measure the performance and protection of the skin to collect.
8th Place the client in low or semi-Fowler position.
Rationale: Facilitates drainage of bile.
Monitor ninth injection (4:57) in endoscopic procedures.
Reason: These areas may bleed or staples and straps Star may decide to stab wound site.
Take 10th obstruction, bloating or other signs of peritonitis, such as the abdomen, fever and severe right upper quadrant (RUQ) abdominal pain suggests pancreatitis.
Reason: Expulsion T-tube can cause irritation of the diaphragm, or more serious complications such as biliary drainage in the stomach and pancreatic duct is closed.