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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for a client who is 4 days post-operative following a colon resection. The client experiences a severe coughing fit and reports, 'I felt something pop in my stomach.' Upon inspection, the PN notes that the surgical incision has separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first to last.

  1. 1Stay with the client and call for immediate assistance.
  2. 2Position the client in a low Fowler's position with the knees flexed.
  3. 3Cover the protruding organs with sterile dressings moistened with normal saline.
  4. 4Obtain the client's vital signs to monitor for indications of hypovolemic shock.

Answer

The correct sequence is to first stay with the client and call for assistance, then position the client in a low Fowler's position with knees flexed, followed by covering the protruding organs with sterile, saline-moistened dressings, and finally obtaining vital signs.
The correct sequence prioritizes immediate client safety, prevention of further evisceration, tissue protection, and systemic monitoring. Calling for assistance while staying with the client ensures help arrives with necessary supplies without leaving the client unsafe. Positioning in low Fowler's with bent knees immediately reduces tension on the abdominal suture line. Covering the protruding bowel with sterile, saline-moistened dressings prevents necrosis and infection. Finally, monitoring vital signs assesses for complications such as hypovolemic shock while awaiting emergency surgical intervention.

Step-by-Step Solution

1
Ensure immediate safety and obtain assistance.
The nurse stays with the client and calls for help.
Leaving the client could result in further injury or panic; another staff member must bring sterile supplies to the room while the nurse remains at the bedside.
2
Minimize abdominal tension.
The client is placed in a low Fowler's position with knees flexed.
This physical position directly relaxes the abdominal muscles and prevents further protrusion of the bowel.
3
Protect the eviscerated tissue.
The protruding organs are covered with sterile, saline-soaked dressings.
Exposed bowel can quickly become necrotic if it dries out. A moist, sterile environment prevents tissue damage and infection.
4
Assess systemic status.
Vital signs are obtained and continuously monitored.
Wound evisceration can lead to rapid fluid shifts and hypovolemic shock, requiring close hemodynamic monitoring while awaiting emergency surgical intervention.

Key Concept

Management and prioritization of surgical wound evisceration
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Topics

Physiological Adaptation

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