Evisceration is an emergency: cover with sterile moist gauze, do not push organs back in, and call the surgeon now.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse caring for a client with an abdominal surgical wound understands that wound dehiscence has occurred. Which finding most directly indicates dehiscence rather than evisceration?
Answer: B. Dehiscence is the partial or total separation of wound layers without protrusion of organs. A sudden increase in serosanguineous drainage and a feeling that something has "given way" are classic signs. Protruding viscera define evisceration, a more severe complication.
Question 2 of 5
A nurse notes that a surgical wound has dehisced, with the edges separating and the wound partially open. What is the priority nursing action?
Answer: A. For wound dehiscence, the priority is to cover the wound with sterile saline-moistened gauze and notify the surgeon. Keeping the wound moist protects exposed tissue and prevents drying while help is obtained. This also reduces the risk of progression to evisceration.
Question 3 of 5
A nurse assesses a healing surgical wound and observes the wound edges are approximated, with minimal scarring expected. How does the nurse describe this type of healing?
Answer: A. Healing by primary intention occurs when wound edges are well approximated (as in a clean surgical incision closed with sutures or staples), resulting in minimal tissue loss and a fine scar. Secondary intention applies to wounds left open to granulate from the base, such as pressure injuries. Tertiary (delayed primary) intention involves intentionally delayed closure of a contaminated wound.
Question 4 of 5
A nurse is monitoring a client recovering from abdominal surgery for signs that increase the risk of wound dehiscence. Which factor increases this risk?
Answer: A. Obesity, excessive coughing or straining, poor nutrition, infection, and increased abdominal pressure raise the risk of wound dehiscence. Teaching the client to splint the incision with a pillow when coughing helps reduce strain on the suture line.
Question 5 of 5
A nurse inspects a burn wound that is waxy white, leathery, dry, and insensate to touch. The client reports no pain in the area. Which type of burn does the nurse document?
Answer: D. A full-thickness (third-degree) burn destroys the epidermis and dermis, including nerve endings, so the area is painless or has only minimal pain at the wound itself. The wound appears dry, leathery, waxy white, brown, or charred (eschar). Superficial and partial-thickness burns remain painful because nerve endings are intact.
Keep the streak going with more questions like these, each with a full rationale.
What is wound dehiscence and evisceration?
Evisceration is a surgical emergency. They occur most often around days 5-12 postoperatively, frequently after a sudden increase in intra-abdominal pressure such as coughing or straining. The patient may report a feeling that something gave way.
Key points to remember
- Risk factors include obesity, poor nutrition, infection, diabetes, smoking, and increased abdominal pressure.
- A sudden gush of serosanguineous drainage may precede dehiscence.
- Evisceration exposes abdominal contents and demands immediate intervention to prevent shock and infection.
- Adequate protein, vitamin C, and zinc support wound healing and reduce risk.
- Splinting the incision during coughing, vomiting, or movement lowers strain on the wound.
- The peak risk period is roughly postoperative days 5 through 12.
Signs & symptoms
- Sudden gush serosanguineous drain
- Pt 'something gave way'
Nursing priorities
- For evisceration, stay with the patient, call for help, and cover the organs with sterile saline-soaked gauze.
- Position the patient supine with knees slightly flexed (low Fowler's) to reduce abdominal tension.
- Keep the patient NPO and prepare for emergency surgery, and notify the surgeon immediately.
- Monitor for signs of shock and start oxygen and IV access as ordered.
- Teach and ensure incision splinting during any activity that raises abdominal pressure.
Labs & values
Patient teaching
- Support your incision with a pillow whenever you cough, sneeze, vomit, or change position.
- Eat protein-rich foods and follow nutrition guidance to help the wound heal.
- Report immediately if you feel the incision give way or see drainage or anything bulging from it.
Red flags: report now
- Evisceration is an emergency: cover with sterile moist gauze, do not push organs back in, and call the surgeon now.
- Never apply dry dressings or attempt to reinsert protruding organs.
- A sudden increase in serosanguineous drainage or a popping sensation requires immediate assessment.
References
Clinical references for this topic
