Organs visible through the incision — evisceration: cover with sterile saline-moistened gauze, never push them back, 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 the next step: after complete dehiscence, abdominal organs push out through the opening. Both happen when a still-weak incision fails, typically 5 to 8 days after surgery, often after a sudden rise in abdominal pressure from coughing, vomiting, or straining. Deep (fascial) dehiscence and evisceration are surgical emergencies. The nurse must recognize the warning gush of drainage, protect exposed organs with sterile saline-moistened dressings, and get the surgeon immediately.
Key points to remember
- Dehiscence = the wound edges separate, partly or completely. Evisceration = organs push out through a completely separated wound. Every evisceration starts as a dehiscence.
- Superficial dehiscence is separation of the outer wound edges. Deep dehiscence opens the underlying fascia and, like evisceration, is a surgical emergency.
- Warning signs: a sudden gush of serosanguineous drainage, or the client saying something 'gave way' or 'popped.'
- Peak timing is typically postoperative days 5–8, while healing is still early.
- Risk factors: obesity, malnutrition and low albumin, diabetes, smoking, infection, steroid use, older age, cancer, emergency surgery, and raised abdominal pressure from coughing, vomiting, or straining.
- Healing needs protein for collagen; vitamin C or zinc deficiency also impairs healing, and high blood glucose raises infection risk.
- Superficial dehiscence may be managed with an abdominal binder and later closure; deep dehiscence and evisceration are closed in the operating room.
Signs & symptoms
- Sudden gush serosanguineous drain
- Pt 'something gave way'
Nursing priorities
- Stay with the client and call for help so someone else notifies the surgeon, because evisceration needs a return to the operating room.
- Cover exposed organs with sterile gauze moistened with sterile saline and keep it moist, because organs must stay moist and protected until surgery.
- Position low Fowler's with knees slightly flexed, because this relaxes the abdominal muscles and lowers tension on the wound.
- Keep NPO, give oxygen and start IV access as ordered, and prepare for surgery, because the client is going to the OR.
- Monitor vital signs for shock and keep the client calm, because evisceration can progress to shock.
- Teach splinting with a pillow during coughing, sneezing, and vomiting, because it lowers strain on the incision.
Labs & values
Worked example
- Cue: On postoperative day 5 after abdominal surgery, a client coughs hard, says 'something popped,' and loops of bowel are visible in the incision.
- Meaning: Complete dehiscence with evisceration, a surgical emergency.
- Action: Stay, call for help, cover the bowel with sterile saline-moistened gauze, position low Fowler's with knees flexed, keep NPO, and have the surgeon notified.
- Evaluation: The dressing stays moist, vital signs stay stable, and the client goes to the OR for closure.
Patient teaching
- Hold a pillow firmly over your incision whenever you cough, sneeze, vomit, or change position.
- Eat protein-rich foods to help the wound heal; if you have diabetes, keep your blood sugar in range.
- If you feel your incision give way, see a gush of fluid, or see anything bulging out, lie back, don't touch it, and call for help right away.
Memory tricks
- Dehiscence = edges Disconnect; Evisceration = viscera Exit.
Common mistakes
- Pushing protruding organs back into the abdomen. Never reinsert them.
- Using a dry dressing on exposed organs; it must be sterile and saline-moistened.
- Leaving the client to call the surgeon. Stay and send someone else.
- Swapping the terms: dehiscence is separation; evisceration is organs protruding.
Red flags: report now
- Organs visible through the incision — evisceration: cover with sterile saline-moistened gauze, never push them back, and call the surgeon now.
- Sudden gush of serosanguineous drainage or a 'popping' feeling — assess the wound at once for dehiscence.
- Separated incision with exposed fascia or deeper tissue — notify the surgeon now; deep dehiscence is an emergency.
- Rising heart rate or falling blood pressure after evisceration — signs of shock: escalate immediately.
References
Clinical references for this topic
