A nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client coughs forcefully and suddenly states, "I feel like something just popped open." The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. Arrange the following nursing actions in the correct priority order from first to last.
- 1Stay with the client and call for immediate assistance.
- 2Place the client in a low Fowler's position with the knees bent.
- 3Cover the protruding bowel with sterile dressings soaked in sterile 0.9% sodium chloride.
- 4Assess the client's vital signs and monitor for signs of shock.
- 5Notify the surgeon and prepare the client for emergency surgery.
Answer
The correct priority sequence for managing a surgical evisceration is: stay with the client and call for assistance, position the client in a low Fowler's position with bent knees, cover the exposed bowel with sterile moist dressings, assess vital signs, and then notify the surgeon.
Wound evisceration is a physiological emergency requiring swift, sequential action. The nurse must first ensure safety by staying with the client and calling for help. Next, reducing mechanical tension on the abdomen by placing the client in a low Fowler's position with bent knees prevents further organ protrusion. Protecting the exposed tissue with sterile, saline-soaked dressings is the next critical priority to prevent tissue necrosis and infection. Once the site is secured and protected, assessing vital signs is necessary to evaluate for shock. Finally, the provider is notified with all assessment data to arrange for immediate surgical repair.
Step-by-Step Solution
Key Concept
Management of a postoperative abdominal evisceration requires immediate, sequential actions to reduce abdominal tension, protect the exposed viscera from necrosis and infection, and prepare the client for emergency surgery.