A nurse is caring for a client who is 4 days postoperative following a median laparotomy. The client coughs forcefully and reports a 'giving way' sensation in the abdomen. The nurse inspects the incision and observes bowel loops protruding through the open wound. In what order should the nurse perform the following actions to minimize the risk of tissue necrosis and physiological decompensation?
- 1Call for immediate assistance while remaining with the client.
- 2Position the client in low Fowler's with the knees flexed.
- 3Cover the protruding organs with sterile, saline-soaked dressings.
- 4Assess the client's vital signs and peripheral perfusion.
- 5Notify the surgeon and prepare the client for emergency surgery.
Answer
The correct sequence is to first call for assistance while staying with the client, then position the client to reduce abdominal tension (low Fowler's with knees flexed), cover the exposed organs with moist sterile dressings, assess vital signs for shock, and finally notify the surgeon for emergency operative repair.
Wound evisceration is an acute surgical emergency that requires a rapid, prioritized response to reduce physiological risk. The immediate goal is to prevent further tissue damage by staying with the client and reducing abdominal tension (positioning). Once further evisceration is prevented, the priority is tissue preservation (saline dressings). Only after the wound is secured should the nurse assess systemic status (vital signs) and escalate to the surgeon with complete data.
Step-by-Step Solution
Key Concept
Management of Postoperative Wound Evisceration