What should a nurse monitor closely in a patient at risk for evisceration?

Monitoring wound integrity is crucial for a patient at risk for evisceration because this condition involves the protrusion of internal organs through a surgical incision. Ensuring the integrity of the wound allows the nurse to assess whether the surgical site is healing properly and to identify any signs of dehiscence (the separation of wound edges) or the actual occurrence of evisceration at the earliest stage possible. Vigilant observation of the wound can prevent further complications by facilitating timely intervention.

In this context, while fluid intake, pain levels, and nutritional status are important aspects of postoperative care, they do not directly address the immediate risk of evisceration. Fluid intake supports overall recovery, pain management ensures patient comfort, and nutritional status can influence healing. However, monitoring wound integrity specifically targets the risk of evisceration, making it the most relevant focus in this scenario.