During a shift assessment of a client recovering from an exploratory laparotomy 48 hours ago, the client coughs violently. The nurse witnesses the surgical incision suddenly separate, revealing protruding loops of intestine. Arrange the following interventions in the correct chronological sequence to prioritize client safety.
- 1Remain with the client and activate the unit emergency call system for assistance.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the eviscerated tissue with sterile dressings moistened in normal saline.
- 4Obtain a full set of vital signs to monitor for physiological shock.
- 5Prepare the client for immediate transport to the surgical suite.
Answer
The correct priority sequence is: remain with the client and call for help, position the client in low Fowler's with flexed knees, cover the protruding organs with sterile saline-moistened dressings, obtain vital signs to monitor for shock, and prepare the client for emergency surgery.
Wound evisceration is a critical surgical emergency. The nurse's first absolute priority is safety, which means staying with the client and calling for immediate assistance. Second, while waiting for supplies to be brought into the room, the nurse places the client in a low Fowler's position with the knees bent to immediately reduce abdominal muscle tension and prevent further organ protrusion. Third, once supplies are available, the nurse applies sterile, saline-moistened dressings over the exposed intestine to prevent necrosis and infection. Fourth, the nurse assesses vital signs to ensure the client is not entering physiological shock. Finally, the nurse prepares the client for immediate transport to the operating room for definitive surgical management.
Step-by-Step Solution
Key Concept
Emergency Management of Wound Evisceration
Estimated Time:1m 0s