A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?
A.
Covering the wound with sterile gauze moistened with normal saline.
B.
Placing the patient in low Fowler’s position with knees bent.
C.
Calling for assistance and notifying the surgeon.
D.
Applying pressure to the wound edges.
The Correct Answer and Explanation is:
The priority nursing intervention for a patient who has developed wound dehiscence with evisceration on postoperative day 3 is:
C. Calling for assistance and notifying the surgeon.
Explanation:
Wound dehiscence with evisceration is a serious postoperative complication where the wound edges have separated, and internal organs or tissues have protruded through the opening. This condition requires immediate intervention to prevent further complications, such as infection or damage to the exposed organs. Here’s why the priority is to call for assistance and notify the surgeon:
- Immediate Medical Attention: Evisceration represents an urgent surgical complication. The presence of exposed organs increases the risk of contamination and infection. Immediate surgical intervention is often necessary to repair the wound and address any underlying issues. By notifying the surgeon promptly, the patient can receive the required surgical evaluation and management without delay.
- Collaboration and Resources: Calling for assistance ensures that the nurse is not alone in managing the situation. Evisceration requires a team approach, including additional nursing support and possibly other healthcare professionals to assist with patient care and stabilization.
- Appropriate Handling of the Wound: While covering the wound with sterile gauze moistened with normal saline (Option A) and placing the patient in a low Fowler’s position with knees bent (Option B) are important for wound management and patient comfort, these actions are secondary to the primary need for surgical intervention. Although covering the wound is critical to protect the exposed tissues, it does not replace the need for prompt surgical repair.
- Avoiding Further Damage: Applying pressure to the wound edges (Option D) can potentially exacerbate the situation or cause further injury to the tissues. The priority should be to prevent any additional trauma and ensure that the exposed tissues are protected until the surgical team can address the issue.
In summary, notifying the surgeon and calling for assistance are the primary steps in managing evisceration. This ensures that the patient receives timely and appropriate surgical intervention while safeguarding the exposed tissues and preventing complications.