A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?
A.
Instruct the client to lie supine with his knees flexed.
B.
Position the client in semi-Fowler’s position.
C.
Cover the wound with a dry sterile dressing.
D.
Cover the wound with a transparent dressing.
The correct answer and Explanation is :
The correct answer is C. Cover the wound with a dry sterile dressing.
Explanation:
Evisceration is a surgical emergency where the abdominal contents protrude through the incision. Immediate action is crucial to prevent complications such as infection and loss of bowel function.
- Covering the Wound: The primary goal is to protect the exposed organs and tissues. A dry sterile dressing should be used to cover the wound. This helps minimize the risk of contamination and infection. It’s vital to keep the dressing moist to prevent the exposed tissue from drying out; however, if a sterile dressing is not available, a saline-soaked dressing can be used temporarily.
- Positioning: Although positioning the client is important, the most immediate concern is protecting the eviscerated area. Lying supine with knees flexed (Option A) may reduce tension on the incision but does not protect the wound itself. Semi-Fowler’s position (Option B) can provide comfort but does not adequately protect the exposed organs.
- Avoiding Transparent Dressings: While transparent dressings can be useful for other types of wounds, they are not appropriate for evisceration. They do not provide the necessary coverage for large areas or protect against contamination as effectively as sterile dressings.
- Additional Actions: After covering the wound, the nurse should notify the healthcare provider immediately, monitor vital signs for signs of shock, and prepare for potential surgical intervention. The client should also be kept NPO (nothing by mouth) in anticipation of surgery.
In summary, covering the wound with a dry sterile dressing is the most critical and immediate intervention for a client experiencing evisceration, as it helps protect the exposed tissues and reduces the risk of complications while further medical care is organized.