A nurse is caring for a client who is 3 days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "giving way" sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated and a portion of the bowel is protruding. In what order should the nurse perform the following actions? Arrange the actions from first to last.
- 1Stay with the client and call for immediate assistance.
- 2Position the client in a low Fowler's position with the knees flexed.
- 3Cover the exposed bowel with a sterile, saline-moistened dressing.
- 4Obtain the client's vital signs.
- 5Prepare the client for emergency surgery.
Answer
The correct sequence is to first call for assistance, then position the client to reduce abdominal tension, cover the wound to protect the bowel, assess vital signs, and finally prepare for surgery.
Wound evisceration is a surgical emergency. The nurse's immediate priority is to secure assistance without leaving the client. Next, the nurse must intervene to prevent further evisceration by placing the client in a low Fowler's position with flexed knees. Once positioned, the exposed viscera must be protected from drying and necrosis by covering them with sterile, saline-moistened dressings. After the bowel is protected, the nurse assesses for signs of shock by obtaining vital signs. Finally, the client is prepared for emergency surgical repair.
Step-by-Step Solution
Key Concept
Management of Wound Evisceration