Question

a client who had abdominal surgery 24 hour go suddenly reports a pulling sensation and pain in his surgical incision. the nurse check the surgical wound and finds it separated with the intestine protruding. which of the following actions should the nurse take (Select all that apply)

Answer 1

The nurse should stay with the patient, notify the surgical team urgently, cover the exposed organs with sterile saline-soaked gauze, prepare the patient for the possibility of additional surgery, and monitor vital signs carefully.

Step-by-step explanation:

When a patient reports a pulling sensation and pain at a surgical site, with the wound separated and intestines protruding, this is an indication of wound dehiscence with possible evisceration. If evisceration occurs, this is considered a surgical emergency. The following actions should be taken by the nurse:

1. Stay with the client and call for assistance. Immediate help is needed, but the patient should not be left alone.
2. Have someone notify the surgical team immediately, as this situation may require urgent surgical intervention.
3. Gently cover the protruding organs with sterile saline-soaked gauze to keep the tissue moist and reduce the risk of infection and further damage.
4. Prepare the patient for surgery, as they might need to be taken back to the operating room for repair of the dehiscence.
5. Monitor vital signs closely and observe for signs of shock or other complications.

The nurse must act swiftly to ensure the patient's safety and promote the best possible outcome following this severe complication of surgery.