A nurse is evaluating a client who is two days postoperative following an exploratory laparotomy. The client suddenly reports a 'popping' sensation in the abdomen after a forceful cough. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. In what order should the nurse perform the following interventions? (Arrange the actions from first to last)
- 1Stay with the client and activate the unit's emergency response to request assistance.
- 2Position the client in a low-Fowler's position with the knees flexed.
- 3Cover the exposed bowel with sterile dressings moistened with sterile normal saline.
- 4Assess the client's vital signs and monitor closely for signs of hypovolemic shock.
- 5Prepare the client for immediate transport to the operating room.
Answer
The correct sequence of interventions is: 1) stay with the client and call for help, 2) position the client in low-Fowler's with knees flexed, 3) cover the bowel with sterile saline dressings, 4) assess vital signs, and 5) prepare for emergency surgery.
Wound evisceration is a severe postoperative complication requiring immediate intervention. The sequence of actions is driven by the need to secure assistance, mechanically prevent further organ protrusion, protect the exposed tissues, monitor systemic perfusion, and definitively treat the complication in surgery.
Step-by-Step Solution
Key Concept
Management of Abdominal Wound Evisceration
Estimated Time:1m 30s