Abdominal Surgery Essay Discussion Paper
A nurse is evaluating a client who had abdominal surgery yesterday. When asked about pain and discomfort, the client responds, “1 think I felt something tear in my incision.: The nurse removes the dressing and sees a loop of bowel protruding through the incision. Which interventions are taken at this time? (Select all that apply.) a) Contact the surgeon. b) Instruct the client to remain still. c) Place ice packs over the wound d) Place the client in a supine position without a pillow
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When a nurse evaluates a client who has had abdominal surgery and notices that the client reports feeling something tear in their incision, it is crucial to assess the wound immediately to determine the cause and extent of the problem.
The nurse should follow the following steps to manage the situation appropriately:
- Remove the dressing: The nurse should carefully remove the dressing to evaluate the wound site and identify any visible signs of a bowel loop protruding through the incision.
- Observe the wound: The nurse should assess the size and shape of the wound, any visible signs of inflammation, bleeding, or infection, and check for any signs of dehiscence or evisceration.
- Assess the client: The nurse should ask the client about the nature of the pain, its location, and severity. They should also evaluate the client’s vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, to determine if the client is stable or in distress.
A loop of bowel protruding through the incision is a surgical emergency that requires immediate medical attention. Contacting the surgeon, instructing the client to remain still, placing them in a supine position, and covering the exposed bowel with a sterile, moist dressing are crucial interventions that should be taken immediately to prevent further complications. Abdominal Surgery Essay Discussion Paper
- Contact the surgeon immediately: If the nurse identifies a loop of bowel protruding through the incision, they should contact the surgeon immediately, as this is a surgical emergency that requires immediate intervention.
- Instruct the client to remain still: The nurse should advise the client not to move, cough, or strain, as any sudden movements can cause further damage to the incision or bowel.
- Place the client in a supine position without a pillow: The nurse should place the client in a supine position, with their head flat on the bed and no pillow to reduce the pressure on the abdominal area.
- Do not apply ice packs over the wound: Applying ice packs over the wound is not indicated in this case, as it can cause vasoconstriction and reduce blood flow to the area, which can lead to tissue damage.
Monitor the client closely: The nurse should monitor the client’s vital signs, pain, and wound status closely, and report any changes or deterioration to the surgeon immediately.
In summary, the nurse must act quickly and appropriately in this situation, as it is a surgical emergency that requires immediate attention to prevent further complications or damage. Contacting the surgeon, instructing the client to remain still, and placing them in a supine position without a pillow are crucial interventions that should be taken immediately. Abdominal Surgery Essay Discussion Paper