While assisting a client who had abdominal surgery three days ago, the client coughs forcefully and suddenly reports feeling a tearing sensation. Upon inspection, the nurse observes a portion of the small intestine protruding through the open surgical wound. What is the correct priority sequence of nursing actions? Place the interventions in the correct order from first to last.
- 1Remain with the client and activate the emergency call system to request assistance and sterile supplies.
- 2Place the client in a low Fowler's position with the knees slightly flexed.
- 3Cover the protruding internal organs with sterile dressings moistened with sterile normal saline.
- 4Assess the client's vital signs to monitor for indications of hypovolemic shock.
- 5Notify the healthcare provider of the event and the client's current physiological status.
Answer
The correct sequence of actions for an abdominal evisceration is: 1) Remain with the client and call for assistance, 2) Place the client in a low Fowler's position with knees flexed, 3) Cover the protruding organs with sterile moistened dressings, 4) Assess vital signs, and 5) Notify the healthcare provider.
This sequence prioritizes immediate client safety, mechanical reduction of further injury, organ preservation, hemodynamic assessment, and interprofessional communication, following standard protocols for acute surgical emergencies.
Step-by-Step Solution
Key Concept
Management of Abdominal Evisceration