A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
A.
Cover the wound with sterile, saline-soaked gauze.
B.
Raise the head of the bed to a 45° angle.
C.
Hold gentle, direct pressure on the protruding organ
D.
Place the client’s knees in an extended position.
The Correct answer and Explanation is:
The correct action for a nurse to take when managing a client with wound evisceration following abdominal surgery is:
A. Cover the wound with sterile, saline-soaked gauze.
Explanation:
Wound evisceration is a serious complication where the contents of the abdomen protrude through an opening in the wound. This situation requires immediate and appropriate management to prevent further complications such as infection, dehydration, and additional damage to the protruding organs. Here’s a detailed explanation of why covering the wound with sterile, saline-soaked gauze is the correct action:
- Prevention of Infection: Covering the eviscerated wound with sterile, saline-soaked gauze helps to protect the exposed organs from potential contaminants. Since the intestines and other abdominal organs are not usually exposed to the external environment, they are at high risk for infection if not properly covered. The sterile gauze acts as a barrier, reducing the risk of bacteria and other pathogens from entering the wound.
- Moisture Retention: The saline-soaked gauze helps to keep the exposed organs moist. Maintaining moisture is crucial because it prevents the organs from drying out, which could lead to tissue damage and complications. Moist gauze helps to preserve the integrity of the eviscerated tissues until they can be surgically repaired.
- Immediate Care: Immediate application of sterile, saline-soaked gauze is a critical step in managing evisceration while awaiting surgical intervention. It provides a temporary protective measure that stabilizes the situation until the client can be transported to the operating room for definitive treatment.
- Incorrect Actions:
- B. Raise the head of the bed to a 45° angle: This action can increase intra-abdominal pressure, potentially exacerbating the evisceration.
- C. Hold gentle, direct pressure on the protruding organ: Applying pressure to the eviscerated organs could cause additional injury or damage.
- D. Place the client’s knees in an extended position: Extending the knees may increase abdominal pressure, which could worsen the evisceration.
In summary, the immediate and appropriate action in the case of wound evisceration is to cover the wound with sterile, saline-soaked gauze to prevent infection and maintain moisture until surgical intervention can be performed.