The nurse is changing the abdominal surgical dressing of an older patient who has developed pneumonia and a cough. Upon removing the dressing, the nurse notes the situation as pictured below. What should be the nurse's intervention?
Select all that apply.
1. Place saline moistened sterile dressing over the incision.
2. Notify the patient's surgeon of the occurrence.
3. Don sterile gloves and insert the loop of bowel back into the abdomen.
4. Document the presence of a dehiscence in the medical record.
5. Replace the dressing and ask the oncoming shift to advise the physician about the situation when rounds are made.
Correct Answer: 1, 2
This situation depicts an evisceration, which is an emergency situation, not a dehiscence. Older patients may be at greater risk for this postoperative complication because of thinning of the skin and subcutaneous tissues. The tissue must be kept moist, so application of a sterile dressing that is moistened with sterile saline is appropriate. The surgeon should be made aware of the situation immediately, as a return to the OR will probably be necessary, so having the next shift notify the surgeon is wrong. The nurse should not attempt to put the loop of bowel back into the abdomen as this might cause additional trauma. Documentation is not a priority in this emergency situation.
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