A nurse is assessing a client who had an exploratory laparotomy 3 days ago. While the nurse is in the room, the client sneezes forcefully and reports a sudden "popping" sensation. The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. In what order should the nurse perform the following actions to reduce the risk of further complications? Arrange the actions in the correct sequence.
- 1Stay with the client, call for immediate assistance, and instruct a colleague to notify the surgeon.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding bowel with sterile dressings saturated in normal saline.
- 4Obtain the client's vital signs and monitor for manifestations of shock.
- 5Prepare the client for immediate surgical intervention.
Answer
The correct sequence is to first stay with the client and call for help, then position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, assess vital signs for shock, and finally prepare for emergency surgery.
Wound evisceration is a life-threatening complication that requires immediate, prioritized nursing interventions to reduce the risk of tissue necrosis and shock. The nurse must first ensure safety by calling for help while staying with the client. Next, the nurse minimizes further damage by reducing intra-abdominal tension through positioning. The exposed tissue is then protected with sterile, moist dressings. Once the immediate anatomical threat is managed, the nurse assesses the systemic response by obtaining vital signs, and finally, completes preparations for definitive surgical repair.
Step-by-Step Solution
Key Concept
Emergency Management of Wound Evisceration