While performing a morning assessment on a client who underwent an open bowel resection 48 hours ago, the client experiences a sudden, forceful cough. The client states, "Something just gave way in my stomach." The nurse inspects the surgical site and observes that the wound edges have separated with intestinal loops visible outside the abdominal cavity. In what sequence should the nurse perform the following actions? (Arrange the steps in the correct order of priority.)
- 1Call for immediate assistance and direct staff to contact the surgeon.
- 2Place the client in a low Fowler's position with the knees slightly flexed.
- 3Cover the exposed bowel with sterile dressings soaked in sterile normal saline.
- 4Assess the client's vital signs and monitor for indicators of hypovolemic shock.
Answer
The correct sequence of actions for an abdominal evisceration is to first call for help, then position the client to reduce abdominal tension, next cover the exposed organs with moist sterile dressings, and finally assess vital signs to monitor for shock.
Wound evisceration is a surgical emergency requiring rapid, sequential intervention to protect the exposed organs and prevent physiological decompensation. The correct sequence prioritizes immediate support without leaving the client, reducing mechanical tension on the abdomen, protecting visceral tissue viability, and initiating systemic monitoring for shock.
Step-by-Step Solution
Key Concept
Management of Abdominal Evisceration
Estimated Time:1m 30s