What is the immediate nursing action for an evisceration?

What is the immediate nursing action for an evisceration?

• A. Cover the wound with a sterile saline dressing and notify the surgeon immediately.
• B. Apply heat to the area and observe.
• C. Massage the area to reduce tension.
• D. Apply ointment and leave uncovered.

Answer: (A)

In an evisceration, the immediate priority is protecting the exposed abdominal contents. The correct action is to cover the protruding viscera with a sterile saline-moistened dressing and notify the surgeon right away. Keeping the organs moist helps preserve tissue viability and reduces the risk of contamination and rapid tissue damage. Do not try to push the organs back in, do not apply heat or massage, and do not put ointments on the wound. While you’re arranging protection, position the patient flat with the knees bent to lessen abdominal strain, and prepare for rapid transfer to the operating room as ordered by the surgeon. After covering the viscera, continue to monitor the patient’s vital signs and IV status.

In an evisceration, the immediate priority is protecting the exposed abdominal contents. The correct action is to cover the protruding viscera with a sterile saline-moistened dressing and notify the surgeon right away. Keeping the organs moist helps preserve tissue viability and reduces the risk of contamination and rapid tissue damage. Do not try to push the organs back in, do not apply heat or massage, and do not put ointments on the wound. While you’re arranging protection, position the patient flat with the knees bent to lessen abdominal strain, and prepare for rapid transfer to the operating room as ordered by the surgeon. After covering the viscera, continue to monitor the patient’s vital signs and IV status.