Saturday, 6 November 2010

WOUND DEHISCENCE AND EVISCERATION MANAGEMENT

Although surgical wounds typically heal without incident, occasionally the edges of a wound may fail to join or may separate even after they seem to be healing normally. This development, called wound dehiscence, may lead to an even more serious complication: evisceration, in which a portion of the viscera (usually a bowel loop) protrudes through the incision. Evisceration, in turn, can lead to peritonitis and septic shock. (See Recognizing dehiscence and evisceration.) Dehiscence and evisceration are most likely to occur 6 to 7 days after surgery. By then, sutures may have been removed and the patient can cough easily and breathe deeply—both of which strain the incision. Some wound dehiscence may be managed conservatively using a medical approach, such as sterile dressing application and wound monitoring.
  • NURSING ALERT Wound evisceration requires quick intervention to prevent potentially fatal shock; the wound is usually closed in the operating room.
Several factors can contribute to these complications. Poor nutrition—either from inadequate intake or a condition such as diabetes mellitus—may hinder wound healing. Chronic pulmonary or cardiac disease can also slow healing because the injured tissue doesn't get needed nutrients and oxygen. Localized wound infection may limit closure, delay healing, and weaken the incision. Also, stress on the incision from coughing or vomiting may cause abdominal distention or severe stretching. A midline abdominal incision, for instance, poses a high risk of wound dehiscence.
Equipment
Two sterile towels • 1 L of sterile normal saline solution • sterile irrigation set, including a basin, solution container, and 50-ml catheter-tip syringe • several large abdominal dressings • sterile, waterproof drape • linen-saver pads • sterile gloves.
If the patient will return to the operating room, also gather the following equipment: I.V. administration set and I.V. fluids • equipment for nasogastric (NG) intubation • sedative, as ordered • suction apparatus.
Implementation
  • Provide reassurance and support to ease the patient's anxiety. Tell him to stay in bed. If possible, stay with him while someone else notifies the physician and collects the necessary equipment.
  • Place a linen-saver pad under the patient to keep the sheets dry when you moisten the exposed viscera.
  • Using sterile technique, unfold a sterile towel to create a sterile field. Open the package containing the irrigation set, and place the basin, solution container, and 50-ml syringe on the sterile field.
  • Open the bottle of normal saline solution and pour about 400 ml into the solution container. Also pour about 200 ml into the sterile basin.
  • Open several large abdominal dressings, and place them on the sterile field.
  • Put on the sterile gloves, and place one or two of the large abdominal dressings into the basin to saturate them with saline solution.
  • Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape over the dressings to prevent the sheets from getting wet.
  • Moisten the dressings every hour by withdrawing saline solution from the container through the syringe and then gently squirting the solution on the dressings.
  • When you moisten the dressings, inspect the color of the viscera. If it appears dusky or black, notify the physician immediately. With its blood supply interrupted, a protruding organ may become ischemic and necrotic.
  • Keep the patient on absolute bed rest in low Fowler's position (no more than 20 degrees' elevation) with his knees flexed. This prevents injury and reduces stress on an abdominal incision.
  • Don't allow the patient to have anything by mouth to decrease the risk of aspiration during surgery.
  • Monitor the patient's pulse, respirations, blood pressure, and temperature every 15 minutes to detect shock.
  • If necessary, prepare the patient to return to the operating room. After gathering the appropriate equipment, start an I.V. infusion, as ordered.
  • Insert an NG tube and connect it to continuous or intermittent low suction, as ordered.
  • Depending on the circumstances, some of these procedures may not be done at the bedside. For instance, NG intubation may make the patient gag or vomit, causing further evisceration. For this reason, the physician may choose to have the NG tube inserted in the operating room with the patient under anesthesia.
  • Continue to reassure the patient while you prepare him for surgery. Make sure he has signed a consent form and that the operating room staff has been informed about the procedure.
  • Administer preoperative medications to the patient, as ordered.
Special considerations
  • The best treatment is prevention. If you're caring for a postoperative patient who's at risk for poor healing, make sure he receives an adequate supply of protein, vitamins, and calories. Monitor his dietary deficiencies, and discuss any problems with the physician and the dietitian.
  • When changing wound dressings, always use sterile technique. Inspect the incision with each dressing change, and if you recognize the early signs of infection, start treatment before dehiscence or evisceration can occur. If local infection develops, clean the wound as necessary to eliminate a buildup of purulent drainage. Make sure bandages aren't so tight that they limit blood supply to the wound.
Complications
Infection, which can lead to peritonitis and, possibly, septic shock, is the most severe and most common complication of wound dehiscence and evisceration. Caused by bacterial contamination or by drying of normally moist abdominal contents, infection can impair circulation and lead to necrosis of the affected organ.
Documentation
Note when the problem occurred, the patient's activity preceding the problem, his condition, and the time the physician was notified. Describe the appearance of the wound or eviscerated organ; amount, color, consistency, and odor of any drainage; and nursing actions taken. Record the patient's vital signs, his response to the incident, and the physician's actions.
Finally, make sure you change the patient care plan to reflect nursing actions needed to promote proper healing.