A practical nurse is providing care for a client who is 3 days postoperative following an exploratory laparotomy. The client coughs forcefully, and the nurse observes a sudden separation of the surgical incision with loops of bowel protruding. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)
- 1Stay with the client and call for immediate assistance.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding bowel with sterile dressings saturated in sterile normal saline.
- 4Obtain the client's vital signs to assess for indications of shock.
Answer
The correct sequence is to first call for assistance while staying with the client, then position the client to reduce abdominal tension, next cover the exposed organs with moist sterile dressings, and finally obtain vital signs.
When a client experiences wound evisceration, it is a life-threatening complication that requires immediate risk reduction. The priority is always client safety, which begins by calling for help while staying at the bedside. The next immediate physical need is to stop further evisceration by placing the client in a low Fowler's position with flexed knees to reduce abdominal tension. Once the tension is reduced, the nurse must protect the exposed tissue from necrosis by covering it with sterile, saline-soaked dressings. Finally, after the immediate physical threat is stabilized, the nurse assesses vital signs to monitor for shock while waiting for the surgical team.
Step-by-Step Solution
Key Concept
Management of Wound Evisceration