A nurse is assessing a client on postoperative day 3 following an abdominal laparotomy. The client experiences a sudden, forceful episode of coughing, and the nurse observes loops of intestine protruding through the surgical incision. Arrange the following nursing actions in the correct sequence of priority.
- 1Call for immediate assistance while remaining at the client's bedside.
- 2Position the client in low Fowler's with the knees flexed.
- 3Cover the protruding bowel with sterile, saline-soaked dressings.
- 4Assess the client's vital signs and monitor for shock.
- 5Prepare the client for emergency surgical intervention.
Answer
The correct priority sequence is: 1) Call for immediate assistance while remaining at the bedside, 2) Position the client in low Fowler's with knees flexed, 3) Cover the wound with sterile saline-soaked dressings, 4) Assess vital signs, and 5) Prepare the client for surgery.
Wound evisceration is a surgical emergency requiring immediate and prioritized action. The nurse must first ensure safety by calling for help while staying with the client. Second, positioning the client in low Fowler's with flexed knees reduces abdominal tension. Third, the exposed bowel must be immediately protected from drying and necrosis with sterile, saline-soaked dressings. Fourth, vital signs are assessed to monitor for the onset of hypovolemic shock. Finally, the nurse prepares the client for definitive surgical repair.
Step-by-Step Solution
Key Concept
Management of Postoperative Wound Evisceration