🚑 Wound Evisceration – Emergency Nursing Action

Wound evisceration is a serious postoperative complication in which internal organs (usually intestines) protrude through a surgical incision. It requires immediate nursing intervention.

Question: If wound evisceration occurs, what is the immediate nursing action?

(a) Cover the wound with sterile dry gauze
(b) Leave the wound uncovered and pull the skin edges together
(c) Cover the wound with sterile gauze moistened with sterile normal saline (NS)
(d) Cover the wound with water-soaked gauze

✅ Correct Answer: (c) Cover the wound with sterile gauze moistened with sterile NS

Explanation:
In case of evisceration, the exposed organs must be protected from drying and infection. The nurse should immediately:

• Cover the protruding organs with sterile gauze soaked in sterile normal saline
• Keep the patient in low Fowler’s position with knees slightly flexed
• Inform the surgeon immediately
• Prepare the patient for possible emergency surgery

Moist sterile saline dressing prevents tissue drying and reduces the risk of further damage.

Why are the other options incorrect?

(a) Sterile dry gauze → Dry gauze can stick to tissues and cause damage.

(b) Pulling skin edges together → This can cause more injury and is strictly avoided.

(d) Water-soaked gauze → Plain water is not sterile and may increase infection risk.

Exam Emergency Tip:
Evisceration = Cover with sterile normal saline–soaked gauze + Call surgeon immediately.

💚 Exam Objective Nursing – Asha D
Concept clarity • Strong recall • Nursing success