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Difficulty: HardReduction of Risk Potential

A nurse is assessing a client who is 4 days postoperative following an exploratory laparotomy. The client reports feeling a sudden "tearing" sensation in the abdomen after coughing forcefully. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. Place the following nursing interventions in the correct order of priority.

  1. 1Call for immediate assistance and instruct responding staff to notify the surgeon.
  2. 2Position the client in a low Fowler's position with the knees flexed.
  3. 3Cover the protruding bowel with sterile dressings moistened with sterile 0.9% sodium chloride.
  4. 4Assess the client's vital signs to monitor for indications of shock.
  5. 5Prepare the client for emergency surgical intervention.

Answer

The correct priority sequence is: 1) Call for immediate assistance, 2) Position the client in low Fowler's with flexed knees, 3) Cover the organs with sterile saline-moistened dressings, 4) Assess vital signs, and 5) Prepare the client for emergency surgery.
The correct priority addresses immediate safety first, followed by tension reduction, tissue preservation, systemic assessment, and definitive treatment. Calling for assistance ensures help arrives while the nurse remains with the client. Positioning the client with knees flexed immediately reduces abdominal tension. Covering the organs prevents tissue necrosis. Assessing vital signs evaluates for shock, and preparing for surgery anticipates the necessary medical intervention.

Step-by-Step Solution

1
Call for immediate assistance and instruct responding staff to notify the surgeon.
The primary nurse secures help and initiates the medical response while remaining at the client's bedside.
Leaving the client increases the risk of further injury and severe anxiety. Help is required to gather supplies.
2
Position the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure decreases, and tension on the suture line is relieved.
This is the most critical immediate physical intervention to prevent further protrusion of the abdominal contents.
3
Cover the protruding bowel with sterile dressings moistened with sterile 0.9% sodium chloride.
The exposed bowel is protected from the external environment.
Sterile, moist dressings prevent the bowel tissue from drying out, protecting it from irreversible ischemia.
4
Assess the client's vital signs to monitor for indications of shock.
A baseline assessment of the client's hemodynamic status is obtained.
The client is at extreme risk for shock due to fluid shifts and severe physical stress.
5
Prepare the client for emergency surgical intervention.
The client is readied for definitive medical treatment.
Wound evisceration is a surgical emergency requiring operative repair.

Key Concept

Management of Wound Evisceration
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Topics

Reduction of Risk Potential

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