RECOGNIZING DEHISCENCE AND EVISCERATION

Posted by Admin in Saturday, November 27, 2010

In wound dehiscence (top), the layers of the surgical wound separate. In evisceration (bottom), the viscera (in this case, a bowel loop) protrude through the surgical incision.


Wound dehiscence



Evisceration of bowel loop

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TYPES OF ADHESIVE SKIN CLOSURES

Posted by Admin in Sunday, November 14, 2010

Steri-Strips are used as a primary means of keeping a wound closed after suture removal. They're made of thin strips of sterile, nonwoven, porous fabric tape.

Butterfly closures consist of sterile, waterproof adhesive strips. A narrow, nonadhesive “bridge” connects the two expanded adhesive portions. These strips are used to close small wounds and assist healing after suture removal

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WOUND DEHISCENCE AND EVISCERATION MANAGEMENT

Posted by Admin in Saturday, November 6, 2010

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.

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SKIN STAPLE AND CLIP REMOVAL

Posted by Admin in Monday, November 1, 2010

Skin staples or clips may be used instead of standard sutures to close lacerations or surgical wounds. Because they can secure a wound more quickly than sutures, they may substitute for surface sutures when cosmetic results aren't a prime consideration, such as in abdominal closure. When properly placed, staples and clips distribute tension evenly along the suture line with minimal tissue trauma and compression, facilitating healing and minimizing scarring. Because staples and clips are made from surgical stainless steel, tissue reaction to them is minimal. Usually, physicians remove skin staples and clips, but some facilities permit qualified nurses to perform this procedure.
Skin staples and clips are contraindicated when wound location requires cosmetically superior results or when the incision site makes it impossible to maintain at least a 5-mm distance between the staple and underlying bone, vessels, or internal organs.
Equipment
Waterproof trash bag • adjustable light • clean gloves, if needed • sterile gloves • sterile gauze pads • sterile staple or clip extractor • povidone-iodine solution or other antiseptic cleaning agent • sterile cotton-tipped applicators • optional: butterfly adhesive strips or Steri-Strips, compound benzoin tincture or other skin protectant.
Prepackaged, sterile, disposable staple or clip extractors are available.
Preparation of equipment
Assemble all equipment in the patient's room. Check the expiration date on each sterile package and inspect for tears. Open the waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles. Form a cuff by turning down the top of the bag to provide a wide opening, then preventing contamination of instruments or gloves by touching the bag's edge.
Implementation
  • If your facility allows you to remove skin staples and clips, check the physician's order to confirm the exact timing and details for this procedure.
  • Check for patient allergies, especially to adhesive tape and povidone-iodine or other topical solutions or medications.
  • Explain the procedure to the patient. Tell him that he may feel a slight pulling or tickling sensation but little discomfort during staple removal. Reassure him that because his incision is healing properly, removing the supporting staples or clips won't weaken the incision line.
  • Provide privacy, and place the patient in a comfortable position that doesn't place undue tension on the incision. Because some patients experience nausea or dizziness during the procedure, have the patient recline if possible. Adjust the light to shine directly on the incision.
  • Wash your hands thoroughly.
  • If the patient's wound has a dressing, put on clean gloves and carefully remove it. Discard the dressing and the gloves in the waterproof trash bag.
  • Assess the patient's incision. Notify the physician of gaping, drainage, inflammation, and other signs of infection.
  • Establish a sterile work area with all the equipment and supplies you'll need for removing staples or clips and for cleaning and dressing the incision. Open the package containing the sterile staple or clip extractor, maintaining asepsis. Put on sterile gloves.
  • Wipe the incision gently with sterile gauze pads soaked in an antiseptic cleaning agent or with sterile cotton-tipped applicators to remove surface encrustations.
  • Pick up the sterile staple or clip extractor. Then, starting at one end of the incision, remove the staple or clip. (See Removing a staple.) Hold the extractor over the trash bag, and release the handle to discard the staple or clip.
  • Repeat the procedure for each staple or clip until all are removed.
  • Apply a sterile gauze dressing, if needed, to prevent infection and irritation from clothing. Then discard your gloves.
  • Make sure the patient is comfortable. According to the physician's preference, inform the patient that he may shower in 1 or 2 days if the incision is dry and healing well.
  • Properly dispose of solutions and the trash bag, and clean or dispose of soiled equipment and supplies according to facility policy.
Special considerations
  • Carefully check the physician's order for the time and extent of staple or clip removal. The physician may want you to remove only alternate staples or clips initially and to leave the others in place for an additional day or two to support the incision.
  • When removing a staple or clip, place the extractor's jaws carefully between the patient's skin and the staple or clip to avoid patient discomfort. If extraction is difficult, notify the physician; staples or clips placed too deeply within the skin or left in place too long may resist removal.
  • If the wound dehisces after staples or clips are removed, apply butterfly adhesive strips or Steri-Strips to approximate and support the edges, and call the physician immediately to repair the wound. (See Types of adhesive skin closures.)
  • You may also apply butterfly adhesive strips or Steri-Strips after removing staples or clips even if the wound is healing normally to give added support to the incision and prevent lateral tension from forming a wide scar. Use a small amount of compound benzoin tincture or other skin protectant to ensure adherence. Leave the strips in place for 3 to 5 days.
Home care
If the patient is being discharged, teach him how to remove the dressing and care for the wound. Instruct him to call the physician immediately if he observes wound discharge or any other abnormal change. Tell him that the redness surrounding the incision should gradually disappear and that after a few weeks, only a thin line will be visible.

Documentation
Record the date and time of staple or clip removal, number of staples or clips removed, appearance of the incision, dressings or butterfly strips applied, signs of wound complications, and the patient's tolerance of the procedure.

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REMOVING A STAPLE

Posted by Admin

Position the extractor's lower jaws beneath the span of the first staple (as shown below).


Squeeze the handles until they're completely closed; then lift the staple away from the skin (as shown below). The extractor changes the shape of the staple and pulls the prongs out of the intradermal tissue.

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METHODS FOR REMOVING SUTURES

Posted by Admin

Removal techniques depend on the type of sutures to be removed. The illustrations below show removal steps for four common suture types. Keep in mind that for all suture types, it's important to grasp and cut sutures in the correct place to avoid pulling the exposed (thus contaminated) suture material through subcutaneous tissue.
Plain interrupted sutures
Using sterile forceps, grasp the knot of the first suture and raise it off the skin. This will expose a small portion of the suture that was below skin level. Place the rounded tip of sterile curved-tip suture scissors against the skin, and cut through the exposed portion of the suture. Then, still holding the knot with the forceps, pull the cut suture up and out of the skin in a smooth continuous motion to avoid causing the patient pain. Discard the suture. Repeat the process for every other suture, initially; if the wound doesn't gape, you can then remove the remaining sutures as ordered.



Plain continuous sutures
Cut the first suture on the side opposite the knot. Next, cut the same side of the next suture in line. Then lift the first suture out in the direction of the knot. Proceed along the suture line, grasping each suture where you grasped the knot on the first one.



Mattress interrupted sutures
If possible, remove the small, visible portion of the suture opposite the knot by cutting it at each visible end and lifting the small piece away from the skin to prevent pulling it through and contaminating subcutaneous tissue. Then remove the rest of the suture by pulling it out in the direction of the knot. If the visible portion is too small to cut twice, cut it once and pull the entire suture out in the opposite direction. Repeat these steps for the remaining sutures, and monitor the incision carefully for infection.



Mattress continuous sutures
Follow the procedure for removing mattress interrupted sutures, first removing the small visible portion of the suture, if possible, to prevent pulling it through and contaminating subcutaneous tissue. Then extract the rest of the suture in the direction of the knot.

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