What do nurses do for dehiscence?

Affecting up to 3.4% of patients after abdominopelvic surgery, wound dehiscence is a serious complication requiring immediate attention. This guide will explain precisely what do nurses do for dehiscence, outlining the crucial steps from initial assessment to ongoing management and patient education.

Quick Summary

Nurses manage dehiscence through immediate intervention, including covering the wound with sterile saline dressings, positioning the patient to reduce pressure, and promptly notifying the surgeon. They conduct thorough assessments, monitor for infection, and implement ongoing wound care and patient education to promote healing and prevent further complications.

Key Points

• Immediate Response: In cases of evisceration, a nurse's first action is to stay with the patient, cover the protruding organs with a sterile saline-soaked dressing, position the patient to reduce pressure, and immediately notify the surgeon.

• Thorough Assessment: Nurses continuously assess surgical wounds for signs of dehiscence, such as a popping sensation, pain, increased or changed drainage, redness, swelling, or the absence of a healing ridge.

• Comprehensive Management: Beyond emergency response, nurses manage dehiscence through wound care (e.g., NPWT or regular dressings), administering antibiotics for infection, and providing pain management.

• Patient Education: Educating patients on proper splinting techniques (e.g., using a pillow), activity restrictions (avoiding heavy lifting), nutritional needs, and blood glucose control is a critical preventative nursing intervention.

• Collaboration: Managing dehiscence involves close collaboration with the healthcare team, including surgeons and wound care specialists, to ensure the most appropriate treatment plan is implemented.

• Risk Factor Mitigation: Nurses help mitigate risk factors like poor nutrition and unmanaged diabetes through patient education and by coordinating with other specialists like dietitians.

Recognizing and Responding to Wound Dehiscence

The Critical Role of Early Assessment

Effective management of dehiscence begins with early and accurate assessment. The nurse is often the first to notice the signs of wound separation, which typically occurs within 5 to 8 days post-surgery. A nurse's assessment includes:

• Patient reporting: Listening for a patient's report of a "popping" or "giving way" sensation in the wound, which is a classic sign.
• Visual and tactile inspection: Looking for any separation of the wound edges, noting the depth and length of the separation. A superficial dehiscence involves only the outer layers, while a deeper separation extends to the fascia.
• Drainage: Monitoring for an increase in serosanguinous (pinkish, blood-tinged) or purulent (pus-filled) drainage, which can indicate poor healing or infection.
• Inflammation and pain: Assessing for increased redness, swelling, warmth, or localized pain around the incision site.
• Absence of a healing ridge: By postoperative days 5 to 9, a firm healing ridge should be palpable along the incision line. Its absence can signal impaired healing and impending dehiscence.

Immediate Nursing Interventions for Dehiscence and Evisceration

In the event of a suspected or confirmed dehiscence, and especially in the case of the more severe complication of evisceration (where organs protrude), immediate action is paramount.

Here are the critical steps a nurse takes immediately:

1. Call for help and stay with the patient: The first step is to never leave the patient. Call for another nurse to notify the surgeon and bring sterile supplies.
2. Position the patient: For an abdominal wound, place the patient in a low Fowler's position (head of bed elevated no more than 20 degrees) with knees bent. This position helps to decrease intra-abdominal pressure on the wound site.
3. Cover the wound: Using sterile technique, cover the wound with sterile towels or a sterile dressing soaked in sterile 0.9% sodium chloride. If evisceration has occurred, ensure the protruding organs are completely covered and kept moist.
4. Do NOT attempt to reinsert organs: The nurse must not attempt to push any protruding organs back into the body. This is a medical emergency requiring surgical intervention.
5. Assess and monitor vital signs: Monitor the patient's vital signs every 15 minutes and assess for signs of shock, such as a rapid heart rate or decreased blood pressure.
6. Maintain NPO status: Keep the patient in a "nothing by mouth" (NPO) state in preparation for a potential return to surgery.

Detailed Nursing Care: From Assessment to Prevention

The nursing process for a patient with dehiscence is comprehensive and multifaceted. It includes ongoing monitoring, wound care, pain management, and patient and caregiver education.

Ongoing Wound Management

• Negative-pressure wound therapy (NPWT): For many dehiscence wounds, the surgeon will order NPWT to promote healing by secondary intention. Nurses manage this closed system, ensuring proper application and monitoring its effectiveness. NPWT helps draw fluid out of the wound, increase blood flow, and accelerate granulation tissue growth.
• Dressing changes: Regular wound cleansing and dressing changes with sterile saline and appropriate dressings are crucial to prevent infection and support a moist healing environment. The choice of dressing depends on the wound's size, drainage, and location.
• Infection management: If signs of infection are present, nurses administer prescribed antibiotics and collect wound cultures as ordered to guide treatment.

Preventing Recurrence Through Patient Education

Patient education is a cornerstone of nursing care to prevent further complications. Nurses teach patients and their families about:

• Splinting: Instructing the patient to use a pillow or folded blanket to splint the incision site when coughing, sneezing, or moving. This reduces pressure and stress on the wound.
• Activity restrictions: Educating the patient on avoiding heavy lifting and strenuous activity for the recommended period, often 6 to 8 weeks.
• Nutritional support: Reinforcing the importance of a protein-rich diet to support wound healing. Deficiencies in protein, vitamin C, and zinc can impede the process.
• Monitoring and reporting: Teaching patients and caregivers to recognize the signs of worsening dehiscence or infection and to report them immediately.
• Blood glucose control: For diabetic patients, emphasizing the importance of tight blood glucose control, as hyperglycemia can impair healing.

Dehiscence vs. Evisceration: A Nursing Comparison

Understanding the distinction between dehiscence and evisceration is vital for nursing care. The approach differs significantly in urgency and management.

Feature	Wound Dehiscence	Wound Evisceration
Definition	A partial or total separation of wound edges.	Total separation of wound layers, with protrusion of internal organs.
Classification	Can be superficial or deep, but fascia remains intact with deep dehiscence.	A complete separation of all layers, exposing organs.
Urgency	A serious condition requiring prompt assessment and care.	A medical emergency requiring immediate, specific intervention.
Immediate Action	Assess wound, notify provider, protect and manage wound.	Stay with the patient, cover organs with moist sterile saline dressing, position patient with knees bent, notify provider urgently.
First Aid	Maintain sterile wound environment, decrease pressure.	Cover with moist sterile towels; do not attempt to reinsert organs.

For more detailed information on wound healing and management best practices, consider visiting the Wound Care Education Institute: https://wcei.net.

Conclusion

Nurses are on the front line of recognizing and managing wound dehiscence. Their role encompasses vigilant monitoring, rapid emergency response for evisceration, and meticulous ongoing wound care. By prioritizing patient education and empowering individuals with knowledge of risk factors and proper self-care techniques, nurses contribute significantly to preventing complications and promoting optimal healing outcomes.

Frequently Asked Questions

What is the very first thing a nurse does if they suspect dehiscence with evisceration?

The very first action is to stay with the patient and call for immediate assistance to notify the surgeon. The nurse should then position the patient in a low Fowler's position with knees bent and cover the protruding organs with sterile, saline-soaked towels.

What are the key signs a nurse looks for when assessing for dehiscence?

A nurse looks for a popping sensation reported by the patient, separation of wound edges, increased serosanguinous drainage, redness, swelling, increased pain, and the absence of a firm healing ridge in the incision line by postoperative day 5 to 9.

How do nurses use negative-pressure wound therapy (NPWT) for dehiscence?

Nurses manage NPWT systems, which use negative pressure to remove excess fluid, increase blood flow to the wound, and stimulate the growth of new, healthy granulation tissue. This therapy is often used to manage wounds healing by secondary intention.

What should nurses teach patients to prevent wound dehiscence at home?

Nurses should teach patients to splint the incision with a pillow when coughing or sneezing, avoid lifting heavy objects (often >10 lbs), and ensure adequate nutrition and blood glucose control, especially for diabetic patients.

What is the difference between dehiscence and evisceration for a nurse?

Dehiscence is the separation of wound edges, which can be superficial or deep. Evisceration is a more severe complication where the internal organs protrude through the wound. Evisceration requires immediate, more critical intervention.

Why is patient positioning important for a patient with dehiscence?

For an abdominal wound dehiscence, positioning the patient in a low Fowler's position with knees slightly bent reduces the intra-abdominal pressure and the tension on the surgical incision, which helps prevent further wound separation.

Can nurses administer pain medication for a patient with dehiscence?

Yes, nurses can administer prescribed pain medication to manage the patient's discomfort and anxiety. Effective pain management helps the patient remain calm, which is crucial during an emergency like evisceration.