A nurse is assessing a patient 2 days after open colon resection. On inspection, the surgical abdominal dressing is saturated with serosanguinous fluid. When the nurse removes the dressing, loops of bowel are observed protruding through the separated wound edges. What is this surgical emergency, and what is the immediate nursing action?

Answer and explanation

Correct answer: D. Evisceration; cover protruding bowel with sterile saline gauze and notify surgeon

  1. Step 1: Wound evisceration is the complete separation of wound layers with protrusion of visceral abdominal organs.
  2. Step 2: The immediate nursing priority is remaining calm, placing the patient in a low Fowler's position with knees flexed, covering the exposed bowel with sterile dressings soaked in warm sterile saline to prevent drying and bowel necrosis, and preparing for emergency surgical reclosure.
Answer
Wound Evisceration; Cover the protruding bowel with sterile gauze moistened with sterile normal saline and notify the surgeon immediately.
Why not the others: 'Butterfly adhesive strips' are completely inadequate for visceral protrusion; 'Abdominal binder and coughing' will force more bowel out; 'Manually pushing bowel back' introduces contamination, causes bowel perforation, and is strictly prohibited.

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