A practical nurse (PN) is caring for a client who is 3 days postoperative following a laparotomy. The client reports a "popping" sensation after a severe bout of coughing. Upon inspection, the PN observes that the surgical incision has opened and bowel loops are protruding. In which order should the PN perform the following actions? Arrange the actions from first to last.
- 1Call for immediate assistance while remaining at the client's bedside.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the exposed organs with sterile dressings moistened with sterile 0.9% sodium chloride.
- 4Assess the client's vital signs to evaluate for signs of hypovolemic shock.
Answer
The correct sequence of actions for an abdominal evisceration is to first call for help and stay with the client, then position the client to reduce abdominal tension, next cover the protruding organs with sterile moistened dressings, and finally assess vital signs.
In the event of an evisceration, the primary goal is to protect the exposed organs and prepare for emergency surgery. The nurse must first ensure help is on the way because they cannot leave the client to gather supplies. Immediately positioning the client reduces intra-abdominal pressure to prevent further evisceration. Once the delegated staff brings the sterile supplies, the nurse covers the organs to prevent necrosis. Finally, vital signs are assessed to monitor for shock as the client is prepared for the operating room.
Step-by-Step Solution
Key Concept
The priority management of an abdominal evisceration involves securing help, reducing abdominal tension, protecting the exposed tissue, and monitoring for shock.