A nurse is assessing a client who underwent an exploratory laparotomy three days ago. The client suddenly coughs and reports a sensation of 'giving way' in the abdomen. The nurse inspects the surgical site and observes that a loop of bowel is protruding from the incision. Arrange the following nursing interventions in the correct chronological sequence to mitigate the risk of severe complications.
- 1Remain with the client and call for immediate assistance to obtain sterile supplies.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding viscera with sterile dressings moistened with normal saline.
- 4Assess the client's vital signs and oxygen saturation.
- 5Prepare the client for immediate return to the operating room.
Answer
The correct sequence is to first stay with the client and call for help, then position the client to reduce abdominal tension, cover the eviscerated organs with sterile saline dressings, assess vital signs for shock, and finally prepare the client for emergency surgery.
Wound evisceration is a critical surgical complication requiring rapid, sequential intervention to reduce risk. The immediate priority is maintaining client safety by staying with them and calling for assistance. The next priority is anatomical positioning (low Fowler's with flexed knees) to decrease abdominal tension and prevent further evisceration. Once sterile supplies are brought to the room, the exposed bowel must be protected from drying and infection using saline-soaked sterile dressings. After securing the local wound site, the nurse assesses systemic status via vital signs to monitor for shock, and then prepares the client for definitive surgical repair.
Step-by-Step Solution
Key Concept
Wound Evisceration Emergency Management
Estimated Time:1m 30s