Question

The nurse is caring for obese patient who just had a Roux-en-Y . As the patient is repositioning himself on the bed, he says "Ouch, I felt something pop open!" The nurse inspects the surgical site and sees a portion of the colon protrude from the surgical wound site. Put the following action the nurse would do below:

1.Cover the intestine with sterile moistened gauze

2. Notify the Surgeon

3. Place the patient in semi fowler position with the knees slightly flexed

4. Stay calm and remain with the patient

5. Inspect the protruding intestine.

Please help me on how to put the nursing action in sequencing order with a rationalize for why. Thanks

Answer 1

1) Cover the intestines with sterile moistened clothes to prevent moisture loss and dehydration and prevention of sepsis unless it may leads to shock 2) Place the patient in semi Fowler position with knees slightly flexed to reduce Intraabdonimal pressure for the prevention of further strain on wound 3) Notify the Surgeon to assess the condition of the patient and surgical site for any complications like Haemarrhage. 4) Stay calm and remain with patient to relieve tension and closely monitored for any symptoms of shock 5) Inspect the protruding intestine