Clinical Findings

Neuro: Early signs: anxiety, agitation, restlessness, light-headedness; late signs: decreased LOC, confusion.

Resp: SOB, respiratory distress.

CV:Hypotension (late sign), tachycardia, capillary refill >3 sec, diminished peripheral pulses.

Skin: Coolness, pallor, diaphoresis, cyanosis, mottling, ecchymosis.

GI/GU: Rigid, distended abdomen; periumbilical and/or retroperitoneal bruising, nausea, hematemesis, decreased UO, thirst.

MS: Weakness, fatigue.

Incision: Excessive swelling and ecchymosis.

Other: Excessive wound drainage, saturated dressing, melena, excessive blood loss through chest tube or NGT.

Collaborative Management

• Assess for and control external bleeding with direct pressure.
• Get help and notify surgeon STAT.
• Discontinue any thrombolytics or anticoagulants as ordered.
• Reinforce saturated dressing with additional dressing and pressure. (Do not remove saturated dressing.)
• Lay Pt flat unless contraindicated by respiratory or airway compromise.
• Elevate foot of bed 10°-15°.
• Monitor LOC and orientation.
• Obtain and record outputs (surgical drains, urinary catheter).
• Anticipate and prepare for Pt's return to surgery.