Question

An obese client with diabetes who had a bowel resection 5 days ago says, "I felt like I split open when I was coughing."

On assessment, the nurse notes that the incision edges are separated and a loop of bowel is protruding through the wound.


Which nursing actions would be appropriate?

1. Administer one oral tablet of oxycodone prescribed PRN for pain2. Assess a full set of vital signs3. Cover the viscera with sterile dressings saturated in normal saline (NS) solution4. Notify the health care provider (HCP) immediately5. Place the client in low Fowler's position with knees slightly flexed

Answer 1

Notify HCP immediately.

Step-by-step explanation:

The situation describes surgical wound dehiscence. Specifically - fascial dehiscence (since a loop of bowel is protruding through). Because the fascia has dehisced, this is a surgical emergency as the patient is now at very high risk of life-threatining infection. It wouldn't be as serious if it was just skin/subcutaneous tissue dehiscence because the main barrier between inside and outside is still intact.

HCP must be notified because this patient needs to go back to the OR immediately for repair.