- 0Jul 2, '12 by tomrah84Which is the nurse’s priority nursing action?Place the patient in low-Fowler’s position
or Call the nurses’ station for assistance
Last edit by tomrah84 on Jul 2, '12
- 0Jul 3, '12 by merleeIn these modern times, with all-electric beds that have the call-light built in, this can be done simultaneously.
In the 'olden days' when the beds were hand-cranked - like they were when I was going to school in the Jurassic age - I would say crank first, call second. This is assuming that the patient was in High Fowler's. By lowering the patient you will hopefully minimize further evisceration.
Does this happen very often any more??? I only saw a few dehissences, in many years of bedside nursing, and only one true evisceration. I opened up a few abd pads, and poured sterile saline on them, while trying to keep the patient calm.
Nearly all were either infected or diabetic, and obese.
- 0Jul 3, '12 by Ashley, PICU RNFor test questions like this in nursing school, a good rule of thumb is this: If there is something that the nurse can safely do before calling for help, then that's the first action.
So if the nurse can safely put the patient into low fowlers, or can cover the wound with saline moistened gauze, then those actions come first before calling for help.
Another hint: These sort of test questions are designed to help you think critically and to test that you know how to respond in emergency situations. Very, very rarely is the correct answer to call the doctor or call for help.
- 1Jul 3, '12 by GrnTea, BSN, MSN, RNdepends on where the wound is, silly. :d a thigh dehiscence, while juicy to look at, is not such a big deal as a sternotomy popping open (yep, i've seen that one). be sure you can prioritize depending on what the actual risk to the patient is.
if you're assuming this is an abdominal wound with a true evisceration (where the viscera exit their assigned space), then lowering the head of the bed and raising the knees slightly does two good things: it relieves some of the pressure of the innards on the abdominal wall, and it gets ready for a possible drop in blood pressure from a lot of circulating volume lost to pooling in the innards that are now out-ards. third and fourth good reasons are it decreases the patient's pain and his view of this gawdawful mess, keeping him some calmer.
all of these are going to keep him safer, and safety is the a-numbah-one thang in nursing.