Which statement correctly distinguishes wound dehiscence from evisceration and describes initial nursing management?

Which statement correctly distinguishes wound dehiscence from evisceration and describes initial nursing management?

• A. Dehiscence is separation of wound edges; evisceration is protrusion of internal organs; initial management includes applying ointment and sending to surgery.
• B. Dehiscence is separation of wound edges; evisceration is protrusion of internal organs; initial management includes covering with sterile saline dressings, keeping the patient NPO, placing in low-Fowler's or with knees bent, and calling the surgical team.
• C. Dehiscence and evisceration are the same condition; initial management is to monitor.
• D. Dehiscence is infection; evisceration is bleeding; initial management is to apply heat.

Answer: (B)

Focus on what happens and what to do first. Wound dehiscence means the surgical wound edges separate after closure, while evisceration is when internal organs protrude through that opened wound. The immediate nursing actions are to protect the tissues and stabilize the patient for urgent care. Cover the exposed tissues with sterile, saline-moistened dressings to keep them moist and reduce contamination. Do not try to push anything back in. Place the patient in a position that eases abdominal strain—typically supine with the knees bent or in a low-Fowler’s position—to lessen tension on the incision. Keep the patient calm and NPO while preparing for possible surgical intervention, and promptly call the surgical team for emergent evaluation. This approach prevents drying and infection of exposed tissues, reduces risk of further herniation, and gets the patient to surgery quickly if needed.