On physical examination, the nurse notes that there is separation of layers of a surgical wound. She records it as?

Appeared in: NORCERT 8 Mains-2025

Explanation

Dehiscence is the medical term for the separation of the layers of a surgical wound.
It can be partial, involving only the outer layers, or complete, involving all layers down to the fascia.
The key feature described in the question is 'separation of layers' without mention of organ protrusion, which directly matches the definition of dehiscence.

Option A: Evisceration is incorrect because it involves the protrusion of internal organs through the separated wound, which is a more severe event not described in the question.
Option B: Herniation refers to the protrusion of an organ through a weak point or natural opening in the body wall, not the separation of a surgical incision.
Option C: Prolapse refers to the downward displacement or slipping of an entire organ from its normal position, such as a uterine or rectal prolapse.

Visual 1: Diagram - A side-by-side comparison showing a sutured wound, a wound with dehiscence (gaping layers), and a wound with evisceration (protruding organs). This helps clarify the difference between the key terms.
Visual 2: Photograph - A clinical photograph of an abdominal wound with dehiscence, showing the separated edges without organ protrusion.

Clinical Relevance

Nursing practice connection: Knowing Postoperative Wound Complications helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Recognizing the difference between dehiscence and evisceration is a critical nursing skill, as evisceration is a surgical emergency requiring immediate intervention to prevent tissue death and infection.
Nurses play a key role in preventing dehiscence by educating patients on proper wound splinting (e.g., holding a pillow over the incision when coughing), monitoring nutritional status, and assessing for signs of infection.
What if? If the nurse had noted a gush of serosanguineous fluid from the wound and visible loops of intestine, the correct term would be evisceration, and the immediate priority would be to cover the protruding organs with a sterile, saline-moistened dressing and notify the surgeon urgently.

How to Approach the Question

First, identify the key phrase in the question: 'separation of layers of a surgical wound'.
Next, recall or look up the definitions of the four options provided.
Compare the key phrase from the question to the definitions. 'Dehiscence' is the direct medical term for the separation of wound layers.
Differentiate it from 'evisceration', which is a more severe form that includes organ protrusion.
Eliminate 'herniation' and 'prolapsed' as they describe different types of organ displacement, not the failure of a surgical incision to hold together.

Concept Tested & Keywords

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Practise the full NORCERT 8 Mains-2025

Attempt every question from this paper in a timed mock, then review the full solution for each one.