A nurse is caring for a client who is 2 days postoperative following open abdominal surgery. The client coughs forcefully, and the nurse observes that the surgical incision has completely separated with loops of bowel protruding from the wound. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.
- 1Stay with the client and call for assistance using the call bell.
- 2Place the client in a low Fowler's position with the knees flexed.
- 3Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
- 4Obtain the client's vital signs to monitor for impending shock.
- 5Prepare the client for an immediate return to the operating room.
Cevap
The correct sequence is to first stay with the client and call for assistance, then place the client in a low Fowler's position with knees flexed, cover the viscera with sterile saline-moistened dressings, obtain vital signs, and finally prepare the client for surgery.
Wound evisceration is an acute medical emergency. The priority is to maintain patient safety by staying with them and calling for help. Immediately reducing intra-abdominal pressure by bending the knees and raising the head slightly prevents further organ protrusion. Protecting the exposed tissue with moist, sterile dressings prevents irreversible necrosis. Once the tissue is stabilized, monitoring for shock via vital signs and preparing for definitive surgical repair follow in logical sequence.
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Anahtar Kavram
Management of Wound Evisceration