While performing a routine assessment for a client who is 3 days postoperative from an exploratory laparotomy, a practical nurse observes a loop of bowel protruding through the abdominal incision after the client forcefully sneezes. The client reports a sudden 'popping' feeling. Arrange the following emergency interventions in the correct priority sequence.
- 1Remain at the bedside and activate the emergency call system to request assistance.
- 2Position the client in a low Fowler's position with the knees flexed.
- 3Apply sterile dressings moistened with sterile 0.9% sodium chloride over the exposed bowel.
- 4Obtain a complete set of vital signs to evaluate for impending hypovolemic shock.
Answer
The correct priority sequence is to first call for assistance without leaving the client, then position the client to reduce abdominal tension, next cover the protruding organs with moist sterile dressings, and finally assess vital signs to monitor for shock.
Wound evisceration is a surgical emergency. The nurse's first action is to stay with the client and call for immediate assistance. Next, placing the client in a low Fowler's position with knees flexed reduces tension on the abdominal wall, preventing further evisceration. Once supplies are brought to the room, the nurse covers the protruding organs with sterile, saline-soaked dressings to prevent necrosis. Finally, the nurse obtains vital signs to monitor for shock while preparing the client for emergency surgery.
Step-by-Step Solution
Key Concept
Emergency management of surgical wound evisceration