A nurse is caring for a patient who is postoperative following a total knee replacement. What action should the nurse take to prevent deep vein thrombophlebitis?

 

Choice A rationale:

Serosanguineous drainage is a mixture of blood serum and blood. It is typically thin and watery, with a pinkish or reddish hue.

It is common in the early stages of wound healing, as small blood vessels are injured and release their contents. However, it's not consistent with the yellow and thick drainage described in the question, making it an unlikely choice.

Choice B Rationale:

Serous drainage is clear and watery, composed primarily of blood plasma.

It's also common in the early stages of wound healing and is considered a normal part of the process. However, the clear and watery nature of serous drainage doesn't match the thick, yellow drainage described in the question, ruling out this option.

Choice C Rationale:

Sanguineous drainage is composed primarily of fresh blood.

It's often bright red and may be thick or thin, depending on the amount of bleeding. While sanguineous drainage can indicate a problem, it's typically associated with active bleeding or recent trauma. The yellow color of the drainage in the question makes this choice less likely.

Choice D Rationale:

Purulent drainage is a thick, yellow, green, or brown fluid that often has a foul odor.

It's a sign of infection, as it contains dead white blood cells, bacteria, and debris. The yellow and thick consistency of the drainage described in the question strongly suggests purulent drainage, making it the most likely answer.

Key Points:

The color, consistency, and odor of wound drainage can provide valuable clues about the healing process and potential complications.

Purulent drainage is a hallmark of infection and requires prompt attention.

Nurses play a crucial role in assessing wound drainage and reporting any concerns to the healthcare team.

Choice A rationale:

Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.

Here is a detailed explanation of how anemia can lead to cellular hypoxia:

Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.

Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.

Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.

Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.

Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.

Common signs and symptoms of cellular hypoxia:

Fatigue Weakness

Shortness of breath Pale skin

Dizziness Headache Chest pain

Tachycardia (rapid heart rate) Cognitive impairment