The nurse is caring for an obese client who had a diagnostic laparotomy with midline incision one week ago. The client just called the nurse to report a “popping” sensation in the abdomen. Upon assessment, the nurse notes loops of bowel protruding through the incision. Which is the priority nursing action for this client?
place the client in low Fowler’s with the knees bent
Number 3 is correct.
Rationale: This client is experiencing wound evisceration, which is an emergency. The first priority is to call for help and have the surgeon notified. While waiting on another nurse to bring needed supplies, the nurse stays with the client and positions him in a low Fowler’s with the knees bent to prevent tension on the incision. Monitor vital signs as soon as equipment is available. The wound should be covered with a sterile normal saline dressing and kept moist. After the surgeon arrives, the client is prepared for surgery if ordered.