A nurse is assessing a client who is two days postoperative following an exploratory laparotomy. The client coughs unexpectedly and reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes that a loop of bowel is protruding through the incision. Arrange the following nursing actions in the priority order they should be performed.
- 1Call for help and instruct the client to avoid coughing or straining.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding viscera with sterile, saline-moistened dressings.
- 4Obtain the client's vital signs to assess for physiological instability.
- 5Notify the surgeon to prepare for emergency surgical intervention.
Answer
The correct priority sequence is to first call for help, then position the client to reduce abdominal tension, cover the exposed organs to prevent necrosis, assess vital signs for shock, and finally notify the surgeon.
When an evisceration occurs, the immediate physiological priority is to prevent further protrusion and protect the exposed organs while securing definitive surgical care. The nurse must first secure assistance without leaving the client, then immediately decrease abdominal pressure by placing the client in a low Fowler's position with knees flexed. Once positioned, the exposed bowel must be covered with sterile, moist dressings to prevent necrosis. Only after the wound is protected and vital signs are obtained to check for shock should the nurse notify the surgeon, providing them with a complete and accurate clinical picture.
Step-by-Step Solution
Key Concept
Management of Postoperative Evisceration