The nurse notes evisceration of the client's abdominal incision. Which nursing intervention is the priority before collaborating with the surgeon?
1. Reinforce the wound with a dry sterile dressing.
2. Use Steri-Strips to approximate the wound edges.
3. Ask the client whether coughing or activity is the cause.
4. Cover area with saline solution–moistened sterile towels.
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4. Wound evisceration means internal organs protrude from the incision; thus, the risk of infec-tion is high if the area is exposed. The nurse obtains sterile towels, gloves, and saline solution; moistens the towels; and covers the area. If the client is stable, the nurse instructs the client to remain in place and wait for additional instructions.
1. The nurse avoids a dry dressing because the dressing absorbs moisture from the protruding tissue, increasing the risk of infection or tissue damage.
2. Applying Steri-Strips to a wound evisceration is inadequate because excessive pressure pushed the organs through a weakness in the incision; Steri-Strips are likely to be too weak to withstand the pressure. In addition to sutures or staples, the incision probably needs external support such as a binder.
3. The nurse's priority is to prevent infection and tissue damage; identifying the events leading up to the evisceration can wait for now.
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