A nurse is caring for a client who is recovering from open abdominal surgery. The client coughs forcefully, reports a "popping" sensation, and the nurse observes a wound evisceration. In what order should the nurse perform the following actions? Arrange the steps from first to last.
- 1Stay with the client and call for assistance.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding organs with sterile, saline-moistened dressings.
- 4Obtain the client's vital signs.
- 5Prepare the client for emergency surgery.
Answer
The correct sequence of actions is: 1. Stay with the client and call for assistance, 2. Place the client in a low Fowler's position with the knees flexed, 3. Cover the protruding organs with sterile, saline-moistened dressings, 4. Obtain the client's vital signs, 5. Prepare the client for emergency surgery.
Wound evisceration is a medical emergency requiring rapid, prioritized interventions. First, the nurse must ensure the client's immediate safety by staying with them and calling for help. Second, positioning the client in a low Fowler's position with knees flexed minimizes abdominal tension. Third, protecting the exposed organs with sterile, moist dressings prevents tissue necrosis and infection. Fourth, obtaining vital signs helps monitor for shock. Finally, preparing the client for surgery addresses the definitive treatment.
Step-by-Step Solution
Key Concept
Management of Abdominal Evisceration