Question

A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all.

A. Cover the area w/saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abd.
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the client supine w/his hips & knees bent
E. Offer the client a warm beverage, such as herbal tea

Answer 1

The correct interventions for a patient with a postoperative wound dehiscence and evisceration include covering the area with saline-soaked sterile dressings and positioning the patient supine with hips and knees bent to minimize further wound separation.

Step-by-step explanation:

A client who had abdominal surgery 24 hours ago reports a pulling sensation and pain in his surgical incision, and upon inspection by the nurse, the wound has separated with viscera protruding. The appropriate interventions for this condition, known as wound dehiscence with possible evisceration, are:

• Cover the area with saline-soaked sterile dressings to maintain tissue moisture and prevent further contamination.
• Position the client supine with hips and knees bent to reduce strain on the abdominal area and decrease the risk of further wound separation.

The application of an abdominal binder and pressure to the tissues, as well as offering a warm beverage, are not recommended interventions in this scenario and can exacerbate the situation.