When a post operative patient develops evisceration what a nurse should do?

JIPMER Nursing Officer-2017

Medical & Surgical Nursing

Easy

Appeared in: JIPMER Nursing Officer-2017

Explanation

Wound evisceration is a surgical emergency where internal organs protrude through an incision.
The immediate priority is to cover the exposed organs with a sterile dressing moistened with sterile saline.
This action protects the organs from drying out, contamination, and injury, preserving them for surgical repair.
A multiple-choice question in the reference text confirms that for a patient with an open incision and visible intestines, the priority action is to 'Cover the wound with sterile saline-soaked gauze and notify the surgeon'.

Option A: While providing reassurance is an important nursing action to reduce patient anxiety, it is not the immediate life-saving priority. The physical integrity of the exposed organs must be addressed first.
Option B: This is strictly contraindicated. The patient has a surgical emergency requiring immediate return to the operating room. They must be kept NPO (nothing by mouth) to prevent aspiration during anesthesia.
Option C: This action is extremely dangerous and absolutely contraindicated. Attempting to push organs back into the abdominal cavity can cause further trauma, perforation, compromised blood flow, and introduce widespread infection (peritonitis).

Clinical Relevance

Nursing practice connection: Use the key finding related to Immediate nursing management of postoperative wound evisceration to guide bedside assessment, documentation, and the next nursing action.
Recognizing and correctly managing wound evisceration is a critical, time-sensitive nursing skill that directly impacts patient survival by preventing tissue necrosis and sepsis.
The nurse's role as the first responder is to protect the patient from further harm and stabilize them for emergency surgery.
What if? If the patient experienced wound dehiscence (wound edges separating) but NOT evisceration (no organs protruding), the priority would still be to cover the wound with a sterile dressing and notify the surgeon, but the situation is slightly less emergent than with exposed organs.

How to Approach the Question

First, identify the clinical event described in the question. 'Evisceration' is a specific and serious postoperative complication.
Recall the definition and immediate risks associated with evisceration: organ exposure, tissue drying, and infection.
Prioritize nursing actions based on patient safety. The most urgent need is to protect the exposed organs from harm.
Evaluate each option against this priority. Covering the organs directly addresses the immediate physical threat.
Eliminate options that are contraindicated or less critical. Pushing organs in is harmful, giving fluids is contraindicated before surgery, and providing support is a secondary action.

Concept Tested & Keywords

Concept Tested: Immediate nursing management of postoperative wound evisceration.
Stem keywords: post operative, evisceration, nurse
Lead-in keywords: what a nurse should do

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 129-131