Final answer:
Dehiscence and evisceration are surgical complications that involve the separation of wound layers and protrusion of organs. Nursing care includes assessment, immediate actions like covering organs, and communication for collaboration with the healthcare team.
Step-by-step explanation:
Dehiscence and Evisceration: Nursing Care
Dehiscence is the partial or complete separation of the layers of a surgical incision or wound. It can occur due to factors such as poor wound healing, excessive tension on the wound, infection, or trauma. On the other hand, evisceration is the protrusion of internal organs through the wound, often as a result of dehiscence. Nursing care for dehiscence and evisceration involves several important steps:
- Assessment: Nurses need to assess the patient's wound to determine if it is dehiscing or if evisceration has occurred. They will look for signs such as separation of wound edges or the presence of organs.
- Immediate Actions: In the case of evisceration, the nurse should cover the exposed organs with sterile dressings moistened with saline solution and keep the patient in a position that minimizes abdominal pressure.
- Communication and Collaboration: Nurses should inform the surgeon and the healthcare team immediately about the situation and provide all necessary information for prompt intervention.
Nurses play a critical role in providing appropriate care for patients experiencing dehiscence and evisceration, ensuring early detection and prompt intervention to prevent further complications.
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