Let's review the term "evisceration."
Evisceration is a medical term that refers to the protrusion or displacement of internal organs through a wound or surgical incision. In the context of nursing and the NCLEX exam, it's important to understand this term as it relates to postoperative care and emergency situations.
If evisceration occurs, it is considered a medical emergency. The nurse should recognize the signs, which may include seeing organs or tissues protruding from the incision site, and take immediate action. The appropriate nursing intervention would be to cover the area with sterile saline-soaked gauze to keep the organs moist and minimize the risk of infection, and then to call for medical assistance immediately. The patient should be instructed to lie still in a position that places the least strain on the incision, usually with knees bent to reduce pressure on the abdominal area.
Understanding this term is crucial for the NCLEX because it relates to patient safety, immediate postoperative care, and recognizing signs of complications.
Practice Question
Here's an example NCLEX-style question related to evisceration:
A nurse is caring for a postoperative patient who had an abdominal surgery. Upon assessment, the nurse notices that the patient's surgical incision has reopened and a loop of bowel is protruding through the incision site. The patient is alert and reports severe pain at the site. Which of the following actions should the nurse take FIRST?
A. Apply direct pressure to the site with a sterile, moist saline dressing.
B. Administer prescribed pain medication to alleviate the patient's discomfort.
C. Instruct the patient to cough and deep breathe to assess for further protrusion
D. Notify the surgical team immediately while keeping the organs moist and supported.
Factors to consider for this question:
- Evisceration is a medical emergency.
- The priority is to protect the protruding organs and prevent further injury or infection.
- Pain management is important but not the immediate priority in this scenario.
- Coughing and deep breathing could exacerbate the situation by increasing abdominal pressure.
Correct Answer: D. Notify the surgical team immediately while keeping the organs moist and supported.
Explanation: The first action the nurse should take is to notify the surgical team immediately because evisceration is a surgical emergency that requires prompt intervention. While waiting for the team, the nurse should cover the exposed organs with sterile saline-soaked gauze or towels to keep them moist and minimize the risk of infection and further damage. Direct pressure should not be applied as it could cause more damage to the organs. Pain management and respiratory exercises are secondary to the immediate need to address the evisceration.