護理師照護一位術後放置傑克遜-普拉特(Jackson-Pratt)引流管的病人,下列哪種評估結果顯示有併發症潛在風險?
A nurse is caring for a postoperative client with a Jackson-Pratt drain. Which assessment finding indicates a potential risk of complication?
- ADrainage tube is patent and compressed引流管暢通且處於壓縮狀態
- BSkin around the insertion site is intact插入部位周圍皮膚完整
- COutput is 50 mL of serosanguineous fluid in 8 hours8 小時內排出 50 mL 漿液血色液體
- DDrainage changed from serosanguineous to bright red✓ 正解引流液由漿液血色轉變為鮮紅色
術後引流管(如 Jackson-Pratt, JP drain)的引流液性質應隨時間推移而改變:由術後的血色(Sanguineous),逐漸轉為漿液血色(Serosanguineous),最後變為清澈的漿液色(Serous)。若引流液突然由淺色轉為「鮮紅色」(Bright red),代表傷口內部出現「活動性出血」(Active bleeding)。這是術後嚴重的併發症預兆,必須立即評估病人的生命徵象,檢查凝血功能並通知醫師,以防內出血導致休克。
A change in Jackson-Pratt drain output from serosanguineous to bright red indicates active hemorrhage, which is a serious postoperative complication requiring immediate intervention. Normal drainage progresses from sanguineous to serosanguineous and then to serous; sudden bright red output suggests fresh bleeding. The nurse should assess vital signs and notify the provider promptly.