Clinical Findings

• Low-grade fever, increased WBC count.
• Warm, reddened, tender, swollen, painful wound.
• Separation of wound edges.
• Serous-sanguineous or purulent drainage from wound.
• Purulent discharge from wound drain.
• Feeling of wound tearing or opening.
• Exposure or protrusion of abdominal contents through open wound.

Possible Causes: Infection, excessive tension on suture line (vomiting or coughing), dehydration, long surgery time, hematoma, abdominal distention, obesity, poor nutritional status, diabetes, insufficient suturing, stretching or pulling at suture site (trauma), higher risk in geriatric Pts.

Collaborative Management

• Evisceration—total separation of deep wound layers (fascia and muscle) with protrusion of internal organs and viscera.
• Dehiscence—partial or complete separation of deep wound layers.
• Superficial wound separation—separation of skin and subcutaneous tissue.
• Abdominal wound: If evidence of dehiscence or evisceration, place Pt in semi-Fowler’s position, with knees bent to decrease tension on abdominal wall. Saturate a sterile dressing with NS, and cover open wound. Place a large sterile dressing over top. Do not manipulate viscera or attempt to replace. Keep Pt NPO and notify HCP.
• Dehiscence of wounds elsewhere on body: Position Pt to alleviate tension on suture line, then saturate a sterile dressing with NS, and cover open wound. Place a large sterile dressing over top. Notify HCP immediately.
• Superficial wound separation: Cover wound with a sterile NS wet-to-dry dressing. Notify provider.
• Evidence of infection: Obtain wound culture.
• Assess wound: Determine or describe size, depth, edges, undermining, type and amount of necrotic tissue (color, consistency adherence, and amount), exudate type and amount, color of skin surrounding wound, peripheral tissue edema, induration, granulation tissue, infection. (See Wound Assessment and Documentation Guide in this tab.)
• Assess VS and temp.
• Assess pain level, and administer pain medication as ordered.
• Perform dressing changes as ordered.
• Administer antibiotics as ordered.
• Assess nutritional status; consult dietitian.