Question

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with \(4 \times 4 \mathrm{~s}\) B. Cover the wound with a sterile \(4 \times 4\) and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound

Short answer

Answer: The most appropriate nursing action for a client whose wound eviscerates after a colon resection surgery is to cover the wound with a sterile saline-soaked dressing. This method protects the exposed organs or tissue from further injury and infection while maintaining a moist environment until immediate surgical intervention can be provided.

Step-by-step solution

A patient has experienced wound evisceration following a colon resection surgery. Evisceration refers to the organs or tissue coming out through the surgical incision. This is considered a surgical emergency and requires immediate attention. #Step 2: Evaluate Option A (Reinsert the protruding organ and cover with \(4 \times 4 \mathrm{~s}\))#

It is not within a nurse's scope of practice to reinsert a protruding organ. This action could cause further injury or infection. Therefore, option A is not the most appropriate nursing action for this situation. #Step 3: Evaluate Option B (Cover the wound with a sterile \(4 \times 4\) and ABD dressing)#

A sterile \(4 \times 4\) and ABD (abdominal) dressing is used to cover and protect wounds, but it is not specifically designed or indicated for eviscerated wounds. This option might not provide the required level of protection, and the dressing might not maintain an appropriate moisture balance for the exposed tissue. Thus, option B is also not the most appropriate nursing action for this situation. #Step 4: Evaluate Option C (Cover the wound with a sterile saline-soaked dressing)#

Covering the eviscerated wound with a sterile saline-soaked dressing helps to maintain a moist environment for the exposed tissue and organs while protecting them from further injury and infection. Saline is also effective for wound cleansing due to its isotonic nature. This option would be appropriate for managing an eviscerated wound until a surgeon can assess and treat the patient. #Step 5: Evaluate Option D (Apply an abdominal binder and manual pressure to the wound)#

Applying an abdominal binder and manual pressure may cause more harm to the eviscerated wound. It could risk injury to the exposed organs or tissue and may not provide the appropriate level of care needed for evisceration. Therefore, option D is not suitable for this situation. #Step 6: Determine the answer and rationale#

Based on the evaluation of the four options, the most appropriate nursing action in this case is option C: covering the wound with a sterile saline-soaked dressing. This method protects the exposed organs or tissue from further injury and infection while maintaining a moist environment until immediate surgical intervention can be provided.