Question

The nurse is caring for a client in the postoperative period who had an open colon resection. The nurse attempts to change the dressing but observes the protrusion of intestine through the wound. What is the priority nursing action at this time?

1) Call the health care provider to provide a description of the wound.
2) Cover the wound with a sterile dressing moistened with normal saline.
3) Put the dressing back over the wound until the health care provider arrives.
4) Push the abdominal contents back into the wound and secure with a binder.

Answer 1

The nurse should promptly cover the wound with a sterile saline-moistened dressing and immediately call the healthcare provider because of the surgical site evisceration.

Step-by-step explanation:

The priority nursing action when a nurse observes the protrusion of intestine through a postoperative wound, also known as a surgical site evisceration, is to cover the wound with a sterile dressing moistened with normal saline. It is critical to keep the exposed intestine moist to prevent drying and possible further injury. The nurse should not attempt to push the intestinal contents back in, as this could cause additional harm. The next step is to immediately call the health care provider to inform them of the situation so that rapid surgical intervention can occur.

It is important to maintain a sterile environment to prevent further contamination and infection. In accordance with clinical focus guidelines and standardized postoperative care procedures, immediate action is crucial to ensure the best possible outcome for the patient.