A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse’s first response is to:
A. Call the physician.
B. Place saline-soaked sterile dressings on the wound.
C. Take blood pressure and pulse.
D. Pull the dehiscence closed.
Correct Answer: B. Place saline-soaked sterile dressings on the wound.
The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Ask the client to bend the knees to reduce abdominal tension. Note the color of the tissue before it is covered. Then, cover the moistened dressings with a sterile drape.
Option A: After placing saline-soaked sterile dressings, the nurse should call the physician. The bed should be lowered until it is flat or not higher than 20 degrees. Dehiscence occurs when an incisional wound separates after surgery; evisceration occurs when an internal bodily organ protrudes through the incision. Dehiscence and evisceration can be a life-threatening emergency.
Option C: Take the client’s vital signs and SPO2 while notifying the physician. Check every 15 minutes and assess for signs of shock. The nurse may also start a patent IV line with 0.9% sodium chloride solution for surgery.
Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it. Be prepared to insert a nasogastric tube if ordered, to decompress the stomach. Keep the dressings wet and check the wound frequently, using a new pair of sterile gloves each time.
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