A nurse is assessing a postoperative patient's surgical wound on the second day after abdominal surgery. Which assessment finding would be most concerning and require immediate intervention?

Wound dehiscence is a serious surgical complication involving the separation of fascial layers, potentially leading to evisceration. On the second postoperative day, a gap of 2 cm with visible subcutaneous tissue indicates a failure of wound closure that requires immediate action to prevent infection, further tissue damage, and evisceration.

• Stay with the patient and call for help. Do not leave the patient unattended.
• Cover the wound with sterile, saline-moistened gauze to keep exposed tissue from drying out. Use sterile technique strictly.
• Position the patient supine with knees slightly bent (low Fowler's or semi-Fowler's) to reduce tension on the abdominal incision.
• Notify the surgeon immediately and prepare the patient for a possible return to the operating room for surgical re-closure.
• Monitor vital signs frequently, assessing for signs of shock or infection, and keep the patient NPO in anticipation of surgery.

• Instruct the patient to avoid coughing, straining, or sudden movements. Teach splinting of the incision with a pillow when coughing or deep breathing.
• Assess for risk factors such as obesity, malnutrition, diabetes, smoking, or prolonged steroid use that impair wound healing.
• Document the size, depth, and appearance of the wound separation, along with the time of discovery and interventions performed.
• Provide emotional support, as the patient may experience anxiety or fear upon seeing the open wound.