A nurse is caring for a client who is two days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "popping" sensation in the abdomen. The nurse assesses the surgical site and observes an evisceration. In which order should the nurse perform the following actions to reduce the client's risk of complications? Arrange the actions in chronological order from first to last.
- 1Remain with the client and delegate another staff member to gather sterile supplies.
- 2Position the client in a low-Fowler's position with the knees flexed.
- 3Cover the protruding internal organs with sterile dressings moistened with sterile normal saline.
- 4Assess the client's vital signs and peripheral perfusion.
- 5Communicate the assessment findings and the clinical emergency to the surgeon.
- 6Maintain the client's NPO status and prepare for immediate surgical intervention.
Cevap
The correct sequence is to call for help, position the client, cover the organs, assess vital signs, notify the surgeon, and prepare for surgery.
The correct sequence prioritizes immediate client safety and organ viability. The nurse must first secure help to obtain supplies without abandoning the client. Next, placing the client in a low-Fowler's position with bent knees immediately reduces abdominal tension to prevent further evisceration. Once supplies arrive, covering the exposed organs with sterile, moist dressings is critical to prevent necrosis. Only after the organs are protected should the nurse assess vital signs to evaluate for shock. This assessment provides necessary data for the subsequent step of notifying the surgeon. Finally, the nurse prepares the client for definitive emergency surgery.
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Anahtar Kavram
Emergency management of surgical wound evisceration requires immediate interventions to reduce tension and protect organ viability before assessment and notification.