On day four postop following an open abdominal surgery, the patient develops a cough. During an assessment, the patient coughs, and the wound dehisces. The nurse notes intestinal loops are visible outside of the wound. Which initial intervention by the nurse is appropriate?

Cover the intestines with gauze soaked in warmed sterile normal saline. Following an evisceration, the nurse must protect the integrity of the intestines by covering them with gauze soaked in warmed sterile normal saline. The nurse places the patient in low Fowler’s, not high Fowler’s, with the knees flexed. The nurse stays with the patient and recruits a colleague to contact the surgeon and attending physician; this is not the nurse’s initial action. The patient should be encouraged to relax the abdominal muscles, not engage them, to prevent strangulation of the eviscerated intestines.

On day four postop following an open abdominal surgery, the patie...

Category: Physiological Adaptation
Difficulty: 5

Topics: Communication & Documentation Disease Prevention Gastrointestinal Respiratory

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