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.

Key concepts

Post-Operative Care

After a patient undergoes surgery, they move into the post-operative phase, which is crucial for recovery and healing. This phase involves several key components:

• Monitoring Vital Signs: Nurses frequently check vitals such as heart rate, blood pressure, temperature, and respiratory rate to watch for any signs of complications.
• Pain Management: Pain is common after surgery, and managing it effectively through medications or alternative therapies can help in faster recovery.
• Encouraging Mobility: Early movement, as prescribed by the healthcare provider, can prevent complications like blood clots.
• Nutritional Support: Ensuring the patient receives adequate nutrition helps in wound healing and overall recovery.

Nurses play a pivotal role in this phase by ensuring the patient remains stable and comfortable while alert to any signs of complications that need medical attention.

Wound Management

Proper wound management is critical in preventing infection and promoting healing. In the case of post-operative wounds, the care routine often involves:

• Regular Inspection: Checking the wound for signs of infection, such as redness, swelling, or discharge, is essential.
• Cleansing: Using sterile techniques to clean the wound, often with saline, helps to remove any debris or bacteria.
• Dressing Changes: Depending on the type of wound, dressing changes may vary, but it is generally crucial to keep the wound covering clean and dry.
• Moisture Balancing: Maintaining the right moisture level with appropriate dressings can enhance healing.

For wound evisceration, in particular, using a saline-soaked dressing is best, as this keeps the exposed tissues moist and reduces the risk of infection.

Nursing Interventions

Nursing interventions are actions performed by nurses to ensure patient care and promote recovery. These interventions can be preventive, direct, or indirect.

• Preventive Interventions: This includes educating the patient on proper activity levels post-surgery and how to perform actions safely.
• Direct Care Interventions: Examples include wound dressing and administering medications.
• Monitoring for Complications: Nurses are trained to identify early signs of complications and act promptly, which can involve notifying the surgical team if issues like evisceration occur.
• Psychosocial Support: Providing emotional support and addressing patients' concerns also forms a crucial part of nursing care.

By combining these interventions, nurses play an integral role in facilitating recovery and ensuring the highest standards of post-operative care are met.

Surgical Emergencies

A surgical emergency, such as an eviscerated wound in post-operative care, requires immediate and efficient response. Understanding the critical steps in handling these situations is vital.

• Immediate Action: Protect the exposed organs quickly by using the appropriate dressing, such as a sterile saline-soaked dressing.
• Stabilizing the Patient: Ensure the patient's vitals are stable while preparing to move them to surgical care promptly.
• Collaboration with Surgical Team: Alerting and coordinating with the surgical team is crucial for timely intervention.
• Documentation: Record all actions taken, vital observations, and communications with the healthcare team.

The main goal in such emergencies is to minimize further damage or infection while preparing the patient for surgical correction.