Wound evisceration, what should be the first action?

[jennifer_app]

Okay So on the PDA book, in chapter 16 page 78, they ask what should be the first action you take after noticing a wound evisceration. the answer is 'Check blood pressure' which is different from what i assumed it would be which was "cover wound with saline soaked dressings". I am quite confused as i have seen and heard many places that told me that the priority is to cover the wound with saline soaks.. .

So which one is correct?

thanks

[macuser.girl]

i'd agree that the second one is correct. checking the bp? seriously? at a time like that...... the priority would be safety of the client. safety=placing occlusive dressing over the wound to prevent further injury.

Perioperative Nursing: WOUND COMPLICATIONS

5. Nursing interventions for wound evisceration

1. Place client in supine position.

2. Cover protruding intestinal loops with moist normal saline soaks.

3. Notify physician.

4. Check vital signs.

5. Observe for signs of shock.

6. Start IV line.

7. Prepare client for OR for surgical closure of wound.

[akulahawkRN, ADN, RN, EMT-P]

This is something I learned in my Trauma Courses: as gruesome as an injury looks, you still need to assess your patient. While an eviscerated bowel is an emergency and you'll need to do something about it quickly, you still need to know if your patient has other problems. Assess the ABC's and get a set of vital signs. You're looking for signs of shock. Once you've got that stuff done or as you're getting it done (it only takes a minute or two), remember bowel doesn't dry out instantly, get someone to bring you what you need.

The priority is assessment. Next priority is doing something about what you found.

[macuser.girl]

https://allnurses.com/nclex-discussion-forum/im-officially-confused-683892.html

So here's a similar thread. It seems that different sources have different answers.

You could check out other people's answers as well.

[jennifer_app]

Thanks for the link!!!

[macuser.girl]

no prob