Safe and Effective Care Environment Q 11
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
A. Serum collection (Davol) drain
B. Client’s pain
C. Nutritional status
D. Immobilizer
Correct Answer: A. Serum collection (Davol) drain
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Maintain patency of drainage devices when present. Note characteristics of wound drainage. Reduces the risk of infection by preventing the accumulation of blood and secretions in the joint space (medium for bacterial growth). Purulent, non serous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate the infectious process.
Option B: The client’s pain should be assessed, but this is not life-threatening. Provide comfort measures (frequent repositioning, back rub) and diversional activities. Encourage stress management techniques (progressive relaxation, guided imagery, visualization, meditation). Provide Therapeutic Touch as appropriate. Reduces muscle tension, refocuses attention, promotes a sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period.
Option C: When the client is in less danger, the nutritional status should be assessed. Encourage intake of a balanced diet, including roughage and adequate fluids. Enhances healing and feeling of general well-being. Promotes bowel and bladder function during a period of altered activity.
Option D: An immobilizer is unnecessary in this case. Demonstrate and assist with transfer techniques and use of mobility aids, e.g., trapeze, walker. Facilitates self-care and patient’s independence. Proper transfer techniques prevent shearing abrasions of skin and fall.