A client is 3 days post-operative following an abdominal laparotomy. While coughing forcefully, the client reports a 'giving way' sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated with a loop of bowel protruding. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.
- 1Remain with the client and call for immediate assistance.
- 2Position the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding bowel with sterile dressings soaked in sterile normal saline.
- 4Assess the client's vital signs and monitor for signs of impaired tissue perfusion.
- 5Prepare the client for immediate emergency surgical exploration.
Answer
The correct sequence is: remain with the client and call for help, position the client in low Fowler's with knees flexed, cover the bowel with sterile saline-soaked dressings, assess vital signs, and prepare for emergency surgery.
The correct sequence prioritizes immediate client safety, anatomical tension reduction, tissue preservation, and hemodynamic monitoring. The nurse must first secure the situation by staying with the client and calling for help. Next, placing the client in a low Fowler's position with knees flexed reduces intra-abdominal pressure, preventing further organ protrusion. Once help brings supplies, the nurse covers the bowel with sterile saline-soaked dressings to prevent tissue necrosis and infection. After securing the physical defect, the nurse assesses vital signs to monitor for shock, and finally prepares the client for the definitive surgical intervention.
Step-by-Step Solution
Key Concept
Evisceration emergency management and risk reduction