# Situation: A 48-year-old woman weighing 60 kg returns to the surgical ward after an open abdominal operation under general anesthesia. She has an indwelling urinary catheter and a wound drain. Her preoperative blood pressure was 126/80 mmHg and her heart rate was 80/min. Her daughter stays with her as a watcher. On the sixth postoperative day, after a coughing spell, she says, "Something gave way." The nurse sees loops of bowel protruding through the separated incision. While calling for help and staying with her, which position and wound covering should the nurse use?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629775  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 48-year-old woman weighing 60 kg returns to the surgical ward after an open abdominal operation under general anesthesia. She has an indwelling urinary catheter and a wound drain. Her preoperative blood pressure was 126/80 mmHg and her heart rate was 80/min. Her daughter stays with her as a watcher.

On the sixth postoperative day, after a coughing spell, she says, "Something gave way." The nurse sees loops of bowel protruding through the separated incision. While calling for help and staying with her, which position and wound covering should the nurse use?

## 보기

1. Flat supine, legs straight; saline-moistened sterile dressing
2. Low Fowler's, knees flexed; saline-moistened sterile dressing **✔ 정답**
3. High Fowler's, legs straight; saline-moistened sterile dressing
4. Low Fowler's, knees flexed; dry sterile gauze dressing

**정답: 2**

## 해설

Evisceration is an emergency. Low Fowler's position with knees flexed relaxes the abdominal muscles and reduces tension on the wound, and a sterile dressing moistened with sterile saline keeps the exposed bowel from drying and sticking. The client is kept nothing by mouth (NPO) and the surgeon is notified.

## 심화 해설

Understanding the Emergency

The scenario describes wound evisceration — a full-thickness separation of the surgical incision with protrusion of abdominal contents, in this case loops of bowel. This is a surgical emergency distinct from simple dehiscence, because the exposed bowel is at immediate risk for desiccation, contamination, and vascular compromise. The coughing spell on the sixth postoperative day is a classic precipitating event, as a sudden rise in intra-abdominal pressure stresses a healing but still fragile fascial closure .

The immediate nursing priorities are to reduce tension on the abdominal wall and protect the exposed viscera from drying and infection until surgical repair can be arranged. The patient is kept NPO because emergency laparotomy under general anesthesia is anticipated .

Positioning: Why Low Fowler’s with Knees Flexed

The correct position is low Fowler’s with the knees flexed. This position serves two biomechanical purposes. First, flexing the hips and knees relaxes the rectus abdominis and other anterior abdominal wall muscles, reducing tension on the separated fascial edges. Second, the slight head elevation of low Fowler’s (approximately 15–30 degrees) is more comfortable and physiologically tolerable than flat supine while still avoiding the increased intra-abdominal pressure that would occur in high Fowler’s position. High Fowler’s would pull the abdominal wall taut and could worsen protrusion of the bowel.

| Position | Effect on Abdominal Wall | Appropriateness in Evisceration |
| --- | --- | --- |
| Flat supine, legs straight | Moderate baseline tension; no muscle relaxation from hip flexion | Less effective than knees-flexed position |
| Low Fowler’s, knees flexed | Reduced tension via hip/knee flexion; minimal intra-abdominal pressure increase | Optimal |
| High Fowler’s, legs straight | Increased intra-abdominal pressure; abdominal wall stretched | Contraindicated |

Watch out! Do not attempt to reinsert the bowel into the abdominal cavity. This is outside nursing scope and can introduce bacteria, cause trauma to friable bowel, or trap ischemic loops.

Wound Covering: Saline-Moistened Sterile Dressing

The exposed bowel must be covered with a sterile dressing moistened with sterile normal saline. The moisture serves a critical protective function: it prevents the serosal surface of the bowel from drying out, which would lead to tissue necrosis, adhesion formation, and increased risk of perforation. A dry gauze dressing would adhere to the delicate bowel wall and cause mechanical injury when removed, and it offers no protection against desiccation.

The dressing should be applied loosely, without pressure, and kept moist until the surgical team assumes care. Sterile technique is essential because the peritoneal cavity is now open to the environment, creating a direct portal for bacterial contamination and peritonitis .

Clinical Correlation with the Evidence

Case reports consistently describe evisceration as occurring after a sudden increase in intra-abdominal pressure — coughing, straining, or other Valsalva-type maneuvers — typically between the fifth and tenth postoperative day, when sutures may be intact but fascial healing is still incomplete . The presence of comorbid conditions that impair wound healing, such as diabetes mellitus, chronic obstructive pulmonary disease, or hypertension, increases the risk of fascial dehiscence progressing to evisceration . In the scenario, the patient’s coughing spell is the immediate trigger, and the nurse’s role is to stabilize the situation while summoning surgical assistance.

Key point! The combination of low Fowler’s position with knees flexed and a saline-moistened sterile dressing addresses the two immediate threats: mechanical tension on the wound and desiccation of the exposed bowel. Both interventions are performed while the patient remains NPO and the surgeon is notified for emergency operative repair .

## 임상 시나리오

Evisceration: Immediate Nursing ResponsePositioning and wound covering for protruding bowel
Place the patient in low Fowler's position with knees flexed to relax abdominal muscles and reduce tension on the wound.

Cover the exposed bowel with a sterile dressing moistened with sterile saline to prevent desiccation and contamination.

Keep the patient NPO and notify the surgeon immediately; emergency surgical repair is anticipated.

CautionNever use dry gauze on exposed bowel; it causes drying and adherence. Avoid high Fowler's, which increases intra-abdominal pressure and worsens protrusion.

## 핵심 개념

- **Evisceration** — Full-thickness separation of a surgical incision with protrusion of abdominal contents, a surgical emergency
- **Dehiscence** — Partial or complete separation of wound layers without protrusion of viscera
- **Low Fowler's position** — Supine with head elevated 15-30 degrees, used here with knees flexed to relax abdominal muscles
- **NPO** — Nothing by mouth; required before emergency surgical repair

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