Question

A client's abdominal incision eviscerates. what should the nurse do first?

Answer 1

When abdominal incision evisceration occurs, the nurse should first cover the area with sterile saline-soaked gauze to protect the organs, then immediately notify the surgeon and assist with further treatments as necessary.

Step-by-step explanation:

If a client's abdominal incision eviscerates, the nurse's first action should be to protect the protruding organs and tissue. To do this, the nurse should cover the area with sterile saline-soaked towels or cloths to keep the tissue moist and reduce the risk of infection. Immediately afterward, the nurse should notify the surgeon and prepare to assist with any further medical interventions, which may include emergency surgery to re-secure the abdominal contents.

Procedure in the Event of Evisceration

1. Cover the eviscerated organs with sterile saline-soaked gauze or cloths.
2. Call for medical assistance and inform the surgeon.
3. Prepare to assist with further medical treatment as directed by the surgeon.

These steps follow the critical concept of a 'time out' where the entire team pauses to review aloud the key concerns for the patient's recovery and care before any procedure commences. This would include contingencies like evisceration and how to address them immediately and effectively.