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? Select all that apply.
A Administer one oral tablet of oxycodone prescribed PRN for pain
B Assess a full set of vital signs C Cover the viscera with sterile dressings in NS solution D Notify the health care provider (HCP) immediately E place the client in low Fowler's position with knees slightly flexed
RATIONALE
Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration. Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration. When an abdominal wound evisceration occurs, the nurse should take the following actions:
1. Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the client not to cough or strain.
2. Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury.
3. Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea).
4. Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out.)
Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black).
Option 1) This client should immediately be made NPO in preparation for possible emergency surgery. Only IV analgesics should be administered if the client is in pain.
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