During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound?

Question

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred.  The nurse stays with the client while another staff member gets sterile gauze and saline.  How should the nurse position the client while waiting to cover the wound?

Quizplus · Accepted Answer

Wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. It is considered a medical emergency. The nurse should remain with the client while calling for help. The health care provider should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery. (Option B) Prone positioning would put undue pressure on an open incision and protruding bowel and could contaminate the open wound. (Option C) A side-lying lateral position (recovery position) is often used following emergency situations such as cardiac arrest or seizure, but it will not lessen the tension placed on this open wound. (Option D) Supine with the head of the bed flat may actually increase tension placed on the open wound. Educational objective: Wound evisceration is a medical emergency. The client should be placed in low Fowler's position with the knees bent to reduce tension on the open wound. The nurse should remain with the client while another staff member obtains sterile saline and gauze to cover the wound.

During Assessment of a Client Who Had Major Abdominal Surgery