A practical nurse (PN) is assisting a client who is 2 days postoperative following an abdominal surgery. The client coughs forcefully and reports a sudden "popping" sensation. The PN observes that the surgical wound has completely separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first priority 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 organs with sterile dressings moistened with sterile normal saline.
- 4Measure the client's vital signs to monitor for signs of shock.
- 5Document the occurrence, the interventions taken, and the client's response.
Answer
The correct sequence for managing a wound evisceration is to first stay with the client and call for help, then position the client in low Fowler's with knees flexed, followed by covering the wound with sterile saline-soaked dressings, measuring vital signs, and finally documenting the event.
Wound evisceration is a medical emergency requiring rapid, sequential intervention. The absolute first priority is client safety, meaning the nurse must stay at the bedside and call for help to get the RN, surgeon, and necessary supplies (Step 1). To prevent further protrusion of the bowel, the nurse immediately positions the client in a low Fowler's position with the knees flexed to relax the abdominal muscles (Step 2). Once supplies arrive, the exposed organs must be covered with sterile, normal saline-soaked dressings to prevent tissue drying and necrosis (Step 3). After the organs are protected, the nurse obtains vital signs to monitor for impending shock (Step 4). Finally, once the client is fully stabilized and prepared for return to the operating room, the nurse documents the event (Step 5).
Step-by-Step Solution
Key Concept
Prioritization of Wound Evisceration Management