A practical nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client experiences a vigorous coughing fit and suddenly reports a sensation of something "giving way" in their abdomen. Upon inspection, the nurse observes that the surgical incision has separated and a loop of intestine is protruding. In which order should the nurse perform the following actions? Arrange the steps from first priority to last.
- 1Call for immediate assistance and instruct a colleague to contact the surgeon.
- 2Position the client in low-Fowler's with the knees flexed.
- 3Cover the protruding organs with sterile, saline-moistened dressings.
- 4Obtain a complete set of vital signs to monitor for shock.
- 5Prepare the client for immediate transport to the operating room.
Answer
The correct sequence prioritizes securing immediate help, reducing physical strain on the wound, protecting the exposed tissue, assessing hemodynamic stability, and preparing for definitive surgical repair.
Wound evisceration is a medical emergency requiring rapid, sequential actions to protect the exposed bowel and stabilize the client. The immediate priority is to get help without leaving the client. Next, mechanical tension on the abdomen must be reduced by flexing the client's knees and elevating the head slightly. After reducing tension, the exposed organs are covered with sterile, moist dressings to prevent necrosis. Once the tissue is protected, assessing vital signs for shock becomes the priority before ultimately preparing the client for emergency surgical repair.
Step-by-Step Solution
Key Concept
Prioritization of care during wound evisceration