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Question

Difficulty: HardReduction of Risk Potential

A nurse is caring for a client who is 4 days postoperative following an exploratory laparotomy. The client experiences a severe coughing episode and reports a sudden "tearing" sensation in the abdomen. Upon inspection, the nurse observes a portion of the small intestine protruding through the surgical incision. Place the following nursing actions in the correct chronological order to minimize the risk of tissue ischemia and further complications.

  1. 1Call for immediate assistance and request emergency sterile supplies.
  2. 2Place the client in a low Fowler's position with the hips and knees flexed.
  3. 3Apply sterile, saline-soaked dressings over the protruding abdominal organs.
  4. 4Assess vital signs and monitor the client for indications of hypovolemic shock.
  5. 5Prepare the client for emergency surgical intervention.

Answer

The correct sequence is: Call for assistance, position the client in low Fowler's with flexed knees, cover the organs with sterile saline dressings, assess vital signs, and prepare for emergency surgery.
Managing a wound evisceration requires rapid, prioritized intervention to preserve tissue viability and prevent systemic shock. The absolute priority is safety; the nurse must stay with the client while calling for help to obtain necessary supplies. Immediately following this, positioning the client with a slightly elevated head and flexed knees mechanically reduces intra-abdominal pressure, halting further evisceration. Once sterile supplies are brought to the bedside, covering the exposed bowel with moistened sterile dressings is critical to prevent drying, ischemia, and infection. With the immediate local threat managed, the nurse then assesses systemic stability by monitoring vital signs for shock. Finally, the client is prepared for emergency surgical repair, which is the definitive treatment.

Step-by-Step Solution

1
Call for immediate assistance and request emergency sterile supplies.
Help is initiated without the nurse having to abandon the client.
The nurse must not leave the client alone during a critical evisceration. Another staff member is needed to gather sterile supplies and notify the healthcare provider.
2
Place the client in a low Fowler's position with the hips and knees flexed.
Intra-abdominal pressure is rapidly reduced.
This specific position minimizes tension on the abdominal muscles and the compromised suture line, acting as an immediate mechanical intervention to prevent further bowel protrusion.
3
Apply sterile, saline-soaked dressings over the protruding abdominal organs.
The exposed bowel is protected from environmental drying and contaminants.
Once the requested supplies arrive, the exposed tissue must be kept moist with sterile normal saline to maintain viability, prevent ischemia, and reduce the risk of severe infection.
4
Assess vital signs and monitor the client for indications of hypovolemic shock.
The client's systemic hemodynamic stability is evaluated.
With the immediate local threat to the tissue managed, the nurse must assess for signs of shock (e.g., tachycardia, hypotension) resulting from fluid shifts or potential internal bleeding.
5
Prepare the client for emergency surgical intervention.
The client is readied for definitive operative treatment.
An evisceration cannot be managed conservatively; it requires immediate surgical repair to return the organs to the abdominal cavity and close the fascia.

Key Concept

Prioritization of emergency interventions for surgical evisceration to prevent tissue necrosis and shock.
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Topics

Reduction of Risk Potential

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