NCLEX-PN

Administering Emergency Care for Wound Disruption Wound disruption encompasses two critical conditions: dehiscence and evisceration. Dehiscence signifies the separation of a surgical incision, while evisceration involves the separation of a surgical incision along with the protrusion of an internal bodily organ outside the body through the incision. Both dehiscence and evisceration represent life-threatening emergencies that demand immediate attention. Nurses play a crucial role in providing emergency care by adhering to specific steps: ●​ Continuous Presence : The nurse should not leave the client unattended, ensuring constant vigilance. ●​ Seek Assistance : It's imperative to call for assistance from other healthcare professionals to provide immediate support. ●​ Cover the Wound : Using a clean, sterile towel or sterile saline dampened dressing, the nurse should carefully cover the open wound. ●​ No Reinsertion Attempts : The nurse should refrain from attempting to reinsert the protruding organs. Instead, they should maintain gentle pressure on the wound until a medical doctor arrives to take over. Gastric Lavage One of the medical procedures used in emergencies is gastric lavage, which is used to remove toxic substances , such as poison or drugs, from the stomach. It's crucial to follow proper guidelines to ensure the safety and effectiveness of the procedure. Here's a step-by-step guide to performing gastric lavage : 1.​ Preparation c.​ Explain the procedure to the client or their authorized representative, obtaining informed consent if required. 2.​ Positioning : Place the client in a high Fowler's position whenever possible, as this facilitates tube insertion. 3.​ Tube Selection : Inspect both nares and select the one with no obstructions, such as a deviated septum or narrowing. 4.​ Measuring the Tube : Measure the length of the nasogastric tube from the client's nose to the earlobe and then down to the tip of the xiphoid process. 5.​ Mark this length on the tube using tape to indicate how far the tube should be inserted. a.​ Check the doctor's order and ensure the procedure is indicated and properly documented. b.​ Verify the client's identity using at least two unique identifiers, such as their name and date of birth.

578

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​