A practical nurse (PN) enters the room of a client who is 5 days postoperative following an exploratory laparotomy. The client is coughing forcefully and reports feeling that "my stomach just tore open." The PN observes a loop of intestine protruding through the surgical incision. Arrange the following nursing actions in the correct chronological priority order.
- 1Stay with the client and call for immediate assistance.
- 2Position the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding intestine with sterile dressings moistened with 0.9% sodium chloride.
- 4Assess the client's vital signs to monitor for indications of hypovolemic shock.
- 5Ensure the client remains strictly nothing by mouth (NPO) in preparation for emergency surgery.
Answer
The correct sequence is to first stay with the client and call for assistance, then position the client to reduce abdominal tension, cover the eviscerated organs with a moist sterile dressing, assess vital signs to monitor for shock, and finally ensure NPO status for emergency surgery.
In the event of an evisceration, the primary goals are to prevent further protrusion, protect the exposed organs, and prepare for emergency surgery. The nurse must first call for help while staying with the client. Second, positioning the client with knees flexed reduces intra-abdominal pressure. Third, covering the organs with saline-soaked sterile dressings prevents tissue necrosis. Fourth, monitoring vital signs assesses for shock resulting from fluid loss. Finally, maintaining NPO status prepares the client for immediate surgical repair.
Step-by-Step Solution
Key Concept
Wound Evisceration Management