When caring for postoperative clients, which situation requires the most immediate intervention by the practical nurse (PN)?
A.
A client with diabetes mellitus (DM) develops cellulitis around a foot wound.
B.
Following suture removal from a client’s stab wound, the wound dehisces.
C.
Following abdominal surgery, a client experiences wound evisceration.
D.
A client with a stage 4 sacral pressure ulcer develops purulent drainage.
The correct answer and Explanation is :
The correct answer is C. Following abdominal surgery, a client experiences wound evisceration.
Explanation:
Wound evisceration, where internal organs protrude through a surgical incision, is a medical emergency and requires the most immediate intervention. Evisceration is a severe complication that can occur after abdominal surgery and poses a significant risk for infection, ischemia of the exposed organs, and further damage to the surrounding tissues. The nurse must act quickly to cover the protruding organs with a sterile, saline-moistened dressing to prevent drying, infection, and further injury, and immediately notify the healthcare provider. Surgery is usually required to repair the wound and reposition the organs.
In contrast, the other situations, while concerning, do not require the same level of immediate intervention as wound evisceration:
- A. A client with diabetes mellitus develops cellulitis around a foot wound: While cellulitis in a client with diabetes is serious and needs prompt treatment (typically with antibiotics), it is not immediately life-threatening unless left untreated for a prolonged period. This situation requires intervention but is not an emergency compared to evisceration.
- B. Following suture removal, the wound dehisces: Wound dehiscence, the reopening of a surgical incision, is concerning and requires medical attention but does not usually demand the same immediate action as evisceration. The wound must be cleaned and re-sutured to prevent infection, but it is not as critical as exposed internal organs.
- D. A client with a stage 4 sacral pressure ulcer develops purulent drainage: Purulent drainage indicates infection, which is a serious concern, especially with a stage 4 pressure ulcer. However, immediate life-saving measures are not typically required unless the infection is severe and systemic (e.g., sepsis).
Given the life-threatening nature of evisceration, it requires the most urgent response.