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Difficulty: HardReduction of Risk Potential

A 55-year-old client is 3 days postoperative following an exploratory laparotomy. During a forceful coughing episode, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes an abdominal evisceration. Place the following nursing interventions in the correct priority order to minimize the risk of severe physiological complications. (Arrange the steps from first to last.)

  1. 1Call for immediate assistance and instruct a colleague to bring sterile supplies and notify the surgeon.
  2. 2Position the client in a low Fowler's position with the hips and knees flexed.
  3. 3Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
  4. 4Assess the client's vital signs and monitor for clinical indicators of shock.
  5. 5Verify peripheral intravenous access and prepare the client for emergency surgery.

Answer

The correct priority sequence is: 1) Call for immediate assistance, 2) Position the client in a low Fowler's position with flexed knees, 3) Cover the viscera with sterile moist dressings, 4) Assess vital signs, and 5) Prepare the client for emergency surgery.
In the event of an abdominal evisceration, the overarching goal is to reduce the risk of bowel ischemia, infection, and shock. The nurse must first call for immediate assistance to obtain sterile supplies and alert the surgeon, ensuring they do not leave the unstable client. Before supplies arrive, placing the client in a low Fowler's position with flexed knees immediately relaxes the abdominal musculature, minimizing further organ protrusion. Once the sterile saline and dressings arrive, the nurse covers the exposed viscera to maintain moisture and viability. After securing the physical defect, the nurse evaluates the client's hemodynamic status by checking vital signs to detect early hypovolemic shock. Finally, the nurse verifies intravenous access and prepares the client for the definitive treatment, which is emergency surgical closure.

Step-by-Step Solution

1
Call for immediate assistance and instruct a colleague to bring sterile supplies and notify the surgeon.
The nurse secures additional help and necessary supplies without leaving the client's bedside.
An evisceration is a surgical emergency. The nurse cannot leave the client alone to gather supplies, so mobilizing the team is the first necessary action.
2
Position the client in a low Fowler's position with the hips and knees flexed.
Intra-abdominal pressure is rapidly reduced.
Flexing the knees and raising the head of the bed slightly relaxes the abdominal muscles, reducing tension on the wound and preventing further organ protrusion while waiting for supplies to be brought to the room.
3
Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
The exposed internal organs are protected from the external environment.
Moist, sterile dressings prevent the viscera from drying out, which could lead to severe ischemia and necrosis, while also reducing the risk of bacterial contamination.
4
Assess the client's vital signs and monitor for clinical indicators of shock.
The client's hemodynamic status is systematically evaluated.
Evisceration can lead to rapid fluid shifts and hypovolemic shock. Once the physical wound is stabilized, assessing vital signs is the next critical priority.
5
Verify peripheral intravenous access and prepare the client for emergency surgery.
The client is readied for definitive surgical management.
The only resolution for an evisceration is surgical repair. Ensuring patent IV access allows for fluid resuscitation and administration of preoperative medications.

Key Concept

Abdominal Evisceration Emergency Management Sequence
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Topics

Reduction of Risk Potential

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