The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do?
a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline.
ANS: D
If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the physician immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.
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