What are nursing interventions for wound dehiscence and evisceration?

October 2, 2025 •

4 min read

While wound dehiscence occurs in less than 3% of abdominal surgeries, evisceration can increase mortality risk, making prompt nursing interventions for wound dehiscence and evisceration a critical component of postoperative care. Understanding the immediate steps and long-term management strategies is vital for all nursing professionals.

Quick Summary

Immediate nursing interventions for wound dehiscence involve covering the wound with sterile dressings and notifying the physician; for evisceration, the process is accelerated and involves placing the patient in low Fowler's position, applying saline-soaked sterile dressings to protruding organs without attempting to reinsert them, and preparing for emergency surgery.

Key Points

Immediate Evisceration Action: Position patient low Fowler's, cover with sterile saline-moistened dressings, and notify the surgeon immediately without attempting to reinsert organs.
Minimize Strain: Teach patients to splint their surgical incision with a pillow when coughing, sneezing, or moving to reduce stress on the wound.
Infection Prevention: Maintain strict sterile technique during dressing changes and monitor for signs of infection, such as redness, warmth, or purulent drainage.
Monitor for Impending Dehiscence: Look for increased serosanguineous drainage or a loss of the healing ridge at the incision site as early warning signs.
Optimize Nutrition: Collaborate with a dietitian to ensure the patient has adequate protein, vitamins, and minerals, which are crucial for effective wound healing.
Manage Risk Factors: Address underlying conditions like diabetes and smoking cessation, which can significantly impair wound healing.
Use NPWT Appropriately: Consider negative pressure wound therapy for dehisced wounds to promote healing and manage exudate, as ordered by the healthcare provider.

Understanding Wound Dehiscence and Evisceration

What is Wound Dehiscence?

Wound dehiscence is the partial or total separation of previously approximated wound edges, which can occur most frequently in surgical incisions following abdominal procedures. The wound may open superficially, revealing underlying tissue, but the inner layers of the fascia remain intact. While serious, it is less urgent than evisceration.

What is Wound Evisceration?

Evisceration is the most severe form of dehiscence, where the wound completely opens and internal organs, typically from the abdomen, protrude through the incision. This is a medical emergency that requires immediate intervention to prevent organ damage, infection, and patient shock.

Immediate Nursing Interventions for Evisceration

When evisceration occurs, the nurse must act quickly and calmly. The priority is to protect the exposed organs and prevent further damage while awaiting surgical intervention. The following numbered steps should be followed immediately:

Stay Calm and Call for Help: The first action is to reassure the patient and alert other staff to contact the surgeon immediately. Do not leave the patient unattended.
Position the Patient: Place the patient in a low Fowler's position (head of bed flat or no higher than 20 degrees) with their knees slightly bent. This position reduces abdominal muscle tension and pressure on the wound.
Cover the Wound: Cover the exposed organs with sterile, non-adherent dressings or sterile towels that have been soaked in sterile normal saline. This keeps the tissue moist and protects it from contamination. Do not use dry dressings as they can stick to the organs.
Do Not Reinsert Organs: Under no circumstances should the nurse attempt to push the organs back into the abdomen. This can cause severe trauma and introduce infection.
Assess and Monitor Vitals: Continuously monitor the patient's vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) and assess for signs of shock. An increase in heart rate may be an early sign of complications.
Prepare for Surgery: Keep the patient NPO (nothing by mouth) and ensure a patent IV line is in place and functioning. Be prepared to insert a nasogastric tube if ordered.

Managing Non-Eviscerating Dehiscence

When dehiscence is noted without organ protrusion, the interventions focus on wound protection and preparation for a potential reclosure. These interventions include:

Wound Assessment: Regularly inspect the surgical site for signs of impending dehiscence, such as increasing serosanguineous drainage, redness, or a lack of a healing ridge.
Protective Dressings: Cover the wound with a sterile, moist dressing to protect the open area from contamination and support healing via secondary intention.
Minimize Strain: Instruct the patient to avoid activities that increase intra-abdominal pressure, such as strenuous coughing, vomiting, or heavy lifting.
Splinting: Teach the patient to splint their incision with a pillow or hands when coughing or sneezing. This provides support and minimizes tension on the wound.

Comparison of Interventions


Feature	Wound Dehiscence	Wound Evisceration
Urgency	Requires prompt attention and medical notification.	Immediate surgical emergency.
Covering	Sterile, moist dressings to protect open wound.	Sterile, saline-soaked non-adherent dressings over protruding organs.
Positioning	Restrict movement; may use low Fowler's with bent knees.	Low Fowler's with bent knees to relieve abdominal pressure.
Organ Handling	N/A	Never attempt to reinsert organs.
Vitals Monitoring	Regular vital sign monitoring.	Frequent (e.g., every 15 minutes) vital sign checks for shock.
NPO Status	May not be required initially but is a consideration.	Strictly NPO in preparation for emergency surgery.

Long-Term and Preventative Care Strategies

Beyond the immediate crisis, nursing care focuses on addressing underlying risk factors to promote long-term healing and prevent future complications. For more information on nursing best practices, refer to official resources like those from the American Nurses Association via their website: NursingWorld.org.

Patient Education and Support

Activity Restrictions: Ensure the patient understands and adheres to lifting and activity restrictions. Avoiding heavy lifting for 6-8 weeks is often recommended.
Splinting Technique: Reinforce the splinting technique for any activity that increases intra-abdominal pressure.
Signs of Complications: Educate the patient and family on the signs of infection or re-opening of the wound so they can seek help promptly.

Nutritional Support

Dietary Protein: Adequate protein intake is essential for wound healing. Nurses should collaborate with dietitians to ensure proper nutrition.
Vitamin and Mineral Intake: Ensure the patient receives proper supplementation, as deficiencies in vitamins (especially C) and zinc can impair healing.

Risk Factor Management

Blood Glucose Control: For diabetic patients, meticulous blood glucose control is crucial, as hyperglycemia impairs healing and increases infection risk.
Constipation Prevention: Encourage the use of stool softeners and adequate fiber and fluid intake to prevent straining during bowel movements.
Infection Control: Adhere to strict sterile techniques for wound dressing changes and administer any prescribed antibiotics as ordered to treat or prevent infection.

Advanced Wound Therapies

Negative Pressure Wound Therapy (NPWT): For dehisced wounds, NPWT (also known as a wound vac) may be used to promote granulation tissue formation, manage drainage, and facilitate healing by secondary intention. The nurse is responsible for applying and monitoring this therapy.

Conclusion

Nursing interventions for wound dehiscence and evisceration demand both swift, emergency response skills and diligent, long-term care planning. Evisceration requires a calm, systematic emergency protocol focused on protecting the exposed tissue and preparing for surgery, while dehiscence requires careful wound management and patient education. By executing these interventions with precision and authority, nurses play a critical role in mitigating severe complications and ensuring the best possible outcome for patients facing these serious postoperative events.

Frequently Asked Questions

If a nurse suspects evisceration, the first action is to remain calm and immediately call for help, notifying the surgeon. The patient should not be left alone. Reassure the patient and prepare to position them properly and cover the wound with a sterile, moist dressing.

For both dehiscence and evisceration, the patient should be placed in a low Fowler's position with their knees bent slightly. This positioning helps to decrease intra-abdominal pressure and reduce tension on the surgical incision.

Attempting to push protruding organs back into the abdomen can cause severe trauma to the organs and introduce dangerous bacteria, leading to a high risk of infection. The organs must be covered and protected until they can be handled surgically.

The wound and protruding organs should be covered with sterile, non-adherent dressings or towels that have been saturated with sterile normal saline. This is essential to keep the tissue moist and protected from the external environment.

A nurse can teach a patient to splint their incision by applying pressure to the wound with a pillow or their hands when they cough, sneeze, laugh, or strain. This technique provides support and reduces tension on the surgical site.

Good nutrition, particularly adequate protein and vitamins like Vitamin C and zinc, is crucial for promoting strong tissue synthesis and wound healing. Poor nutritional status is a major risk factor for wound dehiscence.

A healing ridge is a firm line of granulation tissue that forms along a closed surgical incision, usually between 5 and 9 days post-surgery. Its absence can indicate poor healing and an increased risk of dehiscence.