一位具慢性支氣管炎病史的60歲男性，正處於腹部中線大傷口剖腹探查術後的第 3 天。在一陣嚴重、無法控制的狂咳之後，個案尖叫：「有東西剛剛『波』一聲爆掉然後整個撕裂開來了！」護理師衝進去掀開腹部覆蓋物，發現了災難性的傷口臟器外露 (Evisceration)，可清楚看見一圈一圈粉紅色的腸子已經突出到身體外面。護理師必須立刻執行哪些關鍵、拯救生命的介入措施？（多選題）
A 60-year-old male with a history of chronic bronchitis is on postoperative day 3 following a massive exploratory laparotomy with a midline abdominal incision. Following a severe, uncontrollable coughing fit, the client screams, "Something just popped and tore wide open!" The nurse rushes in, exposes the abdomen, and discovers a catastrophic wound evisceration, with loops of pink bowel visibly protruding outside the body. Which critical, life-saving interventions must the nurse implement immediately? (Select all that apply.)
- AStay firmly with the client and shout down the hallway for a colleague to urgently notify the surgeon and bring sterile supplies.✓ 正解堅定地留在病人身旁，並在走廊大喊請同事緊急通知外科醫師並攜帶無菌用品。
- BUsing sterile gloved hands, gently attempt to push the protruding bowel loops back into the abdominal cavity to prevent immediate gangrene.戴著無菌手套，輕輕嘗試將突出的腸圈推回腹腔，以防止立即發生壞疽。
- CImmediately cover the exposed bowel completely with large sterile dressings thoroughly saturated in sterile normal saline.✓ 正解立即用大量浸透無菌生理食鹽水的無菌敷料完全覆蓋外露的腸子。
- DPosition the client flat on his back (supine) with his legs stretched completely straight out to tightly seal the tear.將病人置於仰臥位，雙腿完全伸直，以緊密封閉裂口。
- EInstruct the client to bend his knees and place him in a low Fowler's position to drastically decrease intra-abdominal muscle tension.✓ 正解指示病人彎曲膝蓋，並將其置於低半坐臥姿，以大幅降低腹腔肌肉張力。
本題測驗傷口照護領域中最極端的夢魘級醫療急症：傷口臟器外露（Wound Evisceration）。當縫合的腹部傷口因咳嗽腹壓大增而破裂，伴隨內臟從破洞流出時，這是一場與死神的賽跑。護理師必須維持「絕對不留病患一人獨自面對」的首要安全原則，同時按下緊急呼叫鈴大喊求援（選項A正確）。暴露的腸黏膜若乾燥將導致不可逆的壞死與致死性腸穿孔，必須火速使用浸透了「無菌生理食鹽水」的「大無菌紗布」將外露內臟全數覆蓋並保濕（選項C正確）。腹部張力的控制至關重要，必須讓病患呈現低半坐臥（Low Fowler's position，床頭抬高15-30度）並『彎曲雙膝』。這在解剖學上能最大程度地癱瘓放鬆腹直肌，防止腹壓將更多的腸子硬擠出來（選項E正確；選項D的雙腿伸直是極端錯誤的，這會強力拉緊腹部肌肉，導致傷口被扯更開）。選項B是經典的致死性致命錯誤，絕對不可以試圖將腸子塞回腹腔！這會直接刺穿、扭結腸道並帶來災難性內部感染與敗血症，器官必須留在外面直到外科醫師推進開刀房。
In cases of wound evisceration, the nurse must stay with the client and call for help while covering the exposed organs with sterile, saline-soaked dressings to prevent drying and necrosis. The client should be positioned in a low Fowler’s position with knees bent to reduce intra-abdominal tension and protect the wound.
「不可塞回」、「無菌食鹽水濕紗布覆蓋」、「彎曲膝蓋半坐臥」，這三位一體的 Evisceration 急救口訣是各國外科護理界不容挑戰的國際教條。