The nurse is supervising a student nurse in caring for a postoperative patient at high risk for surgical wound evisceration. The nurse prepares the student to perform which interventions if the wound eviscerates? Select all that apply.

Question

The nurse is supervising a student nurse in caring for a postoperative patient at high risk for surgical wound evisceration. The nurse prepares the student to perform which interventions if the wound eviscerates?  Select all that apply.

Accepted Answer

Take and document vital signs , Call for help and ask the helper to notify the surgeon , Cover the wound with sterile gauze moistened with warmed sterile saline , Keep the dressing continuously moist, adding warmed sterile saline as often as necessary , Place the patient in a supine position with the hips and knees bent and the head of bed raised to 15 degrees. The patient should be assessed and vital signs recorded to prevent complications such as shock. The nurse should stay with the patient, call for help, and have the responder notify the surgeon immediately. Sterile gauze moistened with warmed sterile saline creates a protective barrier while the nurse awaits further instructions from the surgeon. These supplies should be readily available in the patient&rsquo;s room. The dressing should be kept moist to maintain the barrier and prevent tearing of the tissue when it is removed. Pressure is reduced on wounds by flexing the patient at the major joints of knees, hips, and waist. The nurse should not attempt to reinsert organs into the patient&rsquo;s body when surgical wound evisceration occurs.

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