A practical nurse is changing a dressing for a client who is 3 days postoperative following abdominal surgery. The client coughs forcefully, and the nurse observes loops of intestine protruding through the surgical incision. In what order should the nurse perform the following actions? (Arrange the actions from first priority to last priority.)
- 1Remain with the client and call for immediate assistance.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding bowel with sterile, saline-moistened dressings.
- 4Measure the client's vital signs to assess for shock.
- 5Document the evisceration event and the nursing interventions provided.
Cevap
The correct sequence is: 1) Remain with the client and call for immediate assistance, 2) Place the client in a low Fowler's position with the knees flexed, 3) Cover the protruding bowel with sterile, saline-moistened dressings, 4) Measure the client's vital signs, and 5) Document the evisceration event.
In an acute wound evisceration, the primary goal is to prevent further injury and stabilize the client. The practical nurse must first call for help while staying with the client to ensure continuous monitoring. Next, placing the client in a low Fowler's position with flexed knees immediately reduces intra-abdominal pressure. Once supplies arrive, the nurse covers the wound with sterile, moist dressings to preserve tissue viability. Only after the organs are protected from necrosis should the nurse assess vital signs to monitor for shock. Documentation is always the final administrative step, completed once the client is safe.
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Anahtar Kavram
Prioritization of nursing care during wound evisceration requires immediate protection of the client, reduction of abdominal tension, and preservation of the exposed organs, followed by physiological monitoring.