Question

A 75 year old male patient had abdominal surgery a week ago. He has a 5-inch midline abdominal incision, which has staples open to air and a Jackson-Pratt device to suction on the left lower quadrant. The nurse charts he has eaten about one- fourth of his breakfast and lunch. He complains that his wife does not let him get out of bed without calling for assistance; however, his wife is not present today. The nurse tells the patient to ring his call bell so that staff can walk with him, but after lunch the nurse finds the patient alone near his door. "This incision doesn't feel right," he says. On examination, the staples have come loose, and part of his incision is exposed and bulging.

a. What do you suspect is happening? What actions should the nurse take?

Answer 1

The patient is likely experiencing wound dehiscence with possible incisional hernia or evisceration. Immediate actions include notifying the surgeon, positioning the patient to reduce wound tension, applying a sterile dressing, monitoring vitals, and documenting the incident.

Step-by-step explanation:

Given the description of the patient's condition, it is likely that the patient is experiencing a wound dehiscence, which is the reopening of a previously closed wound. The bulging may indicate an underlying incisional hernia or the beginning of an evisceration, where abdominal contents protrude through the wound. Immediate action is required to prevent further complications.

Actions the nurse should take include:

1. Notify the surgeon immediately about the condition of the wound.
2. Assist the patient to a safe position to minimize tension on the wound, preferably supine with the knees slightly elevated to reduce pressure on the abdominal area.
3. Apply a sterile saline-soaked dressing to the exposed area to maintain moisture and prevent infection until medical assistance arrives.
4. Monitor vital signs to detect any signs of shock or infection.
5. Document the incident, including the patient's complaints, physical findings, and the interventions taken.

Proper communication and swift action are crucial in managing wound dehiscence and potential evisceration to ensure the safety and well-being of the patient.