RESPONDING TO the call light, you find Emma Rowe sitting up in bed clutching her abdomen. She says she had a coughing spell, felt a popping sensation, and feels as if “everything is coming out.” Donning gloves, you lift her gown and see that her abdominal incision has opened. Along with the dressing that has lifted, she's holding a loop of bowel against her abdomen.
What's the situation?
Admitted 5 days ago, Mrs. Rowe, 55, is recovering from surgery for a ruptured appendix. She has Type 2 diabetes and is obese. Both conditions put her at high risk for infection and surgical wound dehiscence, a separation of the wound down to the fascia.
Because of her high risk of infection, Mrs. Rowe spent the first two postoperative days in the ICU receiving high-dose I.V. antibiotics. She's now in your surgical unit.
What's your assessment?
Mrs. Rowe has experienced wound dehiscence and evisceration (bowel contents protruding through the abdominal wall). Her vital signs are: BP, 150/96; pulse, 100; respirations, 16; temperature, 98.7° F (37° C); and SpO2, 97% on room air. On a scale of 0 (no pain) to 10 (worst pain), Mrs. Rowe rates her pain as 7. She's also very anxious.
What must you do immediately?
Call for help but stay with your patient. Tell the person who responds to notify the surgeon immediately.
Lower Mrs. Rowe's bed so it's flat or no steeper than 20 degrees. Have her bend her knees to reduce abdominal muscle tension. Open sterile towels and a sterile basin. Soak the towels with sterile saline (or use premoistened sterile dressings). Remove Mrs. Rowe's soiled dressing, quickly don a sterile glove, and place the moistened sterile towels over the loops of bowel. Note the color of the tissue before you cover it: A darkened color may indicate decreased blood supply and the need for immediate surgery.
Cover the moistened towels with a sterile drape. While you notify your supervisor of the change in Mrs. Rowe's condition, have a colleague stay with Mrs. Rowe. Besides reassuring the patient, he should check her vital signs and SpO2 every 15 minutes and assess for signs of shock.
Because Mrs. Rowe will need surgery, make sure she has a patent I.V. line and start an infusion of 0.9% sodium chloride solution, according to facility policy. Be prepared to insert a nasogastric tube if ordered, to decompress the stomach or to remove stomach contents if she was no longer N.P.O. Reassure her and explain the upcoming procedure. Manage her pain and anxiety. Keep the towels wet and check the wound frequently, donning a new pair of sterile gloves each time.
Mrs. Rowe's bowel is pink now. If the color changes to a dusky or dark color, notify the surgeon immediately.
What should be done later?
After the surgical repair of her wound, Mrs. Rowe returns to your unit. Make sure her pain is under control. Teach her how to minimize the risk of another dehiscence and make sure supplies are in the room in case it happens again. Show her how to use a pillow to splint her abdomen when coughing and deep breathing. If the surgeon orders an abdominal binder, show her how to use it. Make sure that her diet includes adequate protein and that her blood glucose is under control. Arrange a consult with the nutritionist if indicated.
Mrs. Rowe will be discharged home in about a week if no more complications develop.