A practical nurse (PN) is performing a routine dressing change for a client who is 4 days postoperative following an abdominal surgery. The client suddenly coughs forcefully, and the PN observes a loop of bowel protruding through the incision line. Arrange the following actions in the order the PN should perform them, 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 organs with sterile, saline-soaked dressings.
- 4Assess the client's vital signs to monitor for symptoms of shock.
Answer
The PN must first call for immediate assistance while remaining with the client, then position the client to decrease abdominal tension, cover the evisceration with sterile moist dressings, and finally monitor vital signs for shock.
Wound evisceration is a critical surgical emergency. The nurse's first priority is to call for help while staying with the client to ensure safety and rapidly mobilize the team. Next, positioning the client in low Fowler's with flexed knees reduces intra-abdominal pressure. Third, covering the wound with sterile, saline-soaked dressings protects the tissue viability. Finally, obtaining vital signs establishes a baseline to monitor for impending shock.
Step-by-Step Solution
Key Concept
Management of Wound Evisceration