A practical nurse (PN) is providing morning care to a client who is 3 days postoperative following an exploratory laparotomy. The client coughs forcefully and reports a "popping" sensation. The PN observes that the abdominal incision has completely separated, with a loop of bowel protruding. Arrange the following nursing actions in the correct priority sequence from first to last.
- 1Call for immediate assistance while remaining with the client.
- 2Position the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding bowel with sterile dressings moistened with sterile normal saline.
- 4Obtain a complete set of vital signs to monitor for signs of shock.
- 5Ensure the client is on strict nothing by mouth (NPO) status and prepare for emergency surgery.
Answer
The correct priority sequence is to first call for assistance while staying with the client, then position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, obtain vital signs to assess for shock, and finally prepare the client for emergency surgery.
Wound evisceration is an acute medical emergency requiring immediate, stepwise intervention. First, the nurse must call for help while remaining at the bedside to ensure safety and escalate care. Second, placing the client in a low Fowler's position with knees flexed minimizes intra-abdominal pressure and halts further organ protrusion. Third, applying sterile, saline-soaked dressings protects the exposed bowel from ischemia and necrosis. Fourth, monitoring vital signs assesses the client for hemodynamic instability and shock. Finally, ensuring NPO status and preparing the client for surgery addresses the definitive medical treatment.
Step-by-Step Solution
Key Concept
The priority management of an abdominal wound evisceration focuses on immediately securing help, minimizing intra-abdominal pressure, and preserving the viability of the exposed organs without leaving the bedside.