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Dehisced abdominal wound

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by

Jennie Uchytil

on 6 October 2013

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Transcript of Dehisced abdominal wound

Ken and Jennie Nursing Concept map
Medication
Enoxoparin (Lovenox)
40 mg/Sub Q/ q 24 h Anti-vascular, anticoagulant, hematologic anticoagulant Helps prevent DVT in pt who is undergoing abdominal surgery Induces thrombocytopenia, mild pain, hematoma hemorrhage, local irritation, erythema
Levofloxacin (Levaquin)
in D5W 500 mg/IV Piggyback/ q 24 hr Fluoroquinlones Used for pnemonia
Metronidazole (Flagyl)
in NaCl 500 mg IV 2 daily Antibiotic Used for anaerobic bacterial infections
Pantoprazole (Protonix
) 40 mg/IV push 2x daily Proton pump inhibitor
Enalaprilat (vasotec)
0.625 mg/0.5 mL/ IV push PRN Ace inhibitor Used for hypertension
Push over 5 mins
Hydomorphine (dilaudid
) 0.5 mg/ML IV push PRN q 2 hr. Opioid analgesic For pain
Magnesium
replacement 1 bag PRN electrolyte Mild 1.5-1.7--Moderate 1-1.4--Severe < 0.9
Metoprolol tartrate (Lopressor)
5 mg/ 5 mL PRN Beta-one blocker, beta one selective used for hypertension, and long term treatment of angina pectoris. Administer with food or immediately after a meal
Ondasetron HCl (Zofran
) PRN Antiemetic; Used for nausea and vomiting Assess client for N/V, abdominal distention, and bowel sounds before and after administration. Assess client for extrapyramidal effects periodically during therapy
Phosphorus
IV replacement PRN Electrolyte Mild 1.7-2.4--Moderate 1.1-1.6--Severe <1.0
Potassium
replacement PRN Electrolyte Mild 3.5-4.0--Moderate 3.1-3.4--Severe <3.0

Pt complains of dry mouth but refused mouth care. Pt says that his unstable HTN is due to radiation treatment he has had for prior cancer treatment. BP can be 148/60 and 10 min later be 216/110. Pt states it hurts too much to cough or use incentive spirometer, and needed lots of encouragement and redirecting to turn or move any of his extremities.
Perception of illness:
Pt appears to be in denial and does not respond to questions pertaining to health care and acts like he is sleeping when social services came to see him.
Affect:
disinterested, anytime education about care for his wounds or teaching opportunities came up he said he was tired and did not care or stared off and did not respond
Emotional support:
did not appear to have or want any support. No family nearby, girlfriend brought to ED, but has not been by to check on him. Report was given that Pt has been non compliant with medication regiment.
Admitting Diagnosis

Dehisced abdominal wound
Client's Initials: ML
Age: 65
Marital Status: Single
Ethnicity: caucasian
Gender: Male
Code Status: Full
Is not religious, has a girlfriend
Lives alone staff thinks possible homeless
Date of Admission: 9-19-2013
Date of Assessment: 9-20-2013

Allergies: Penicillin causes swelling and rash
Height: 5'7"
Weight: 77.1 kg

VS: BP 128/84 P-59 R-16 T-97.5 O2 92% at 3L Pain 9/10
Mental Status: AO/ sedative with meds
Physical exam:
Skin
was color WNL dry, turgor was slow. 18 gauge IV on Left anterior arm. L arm had PICC line. Abdomen appeared irritated and inflamed abdominal surgical incisions 9-3-13 had dehisced with approximately 4 cm X 12 cm opening and another on the RUQ ab about 6 cm X 2.5cm. Pannis was also inflamed, and head of penis had a green/yellow pus ring around the top lip; when cleaned it bled. His toe and finger nails were very thick and untrimmed.
Feet and fingernails had a very foul odor even though a through bed bath had been given the night before.
Head/Neck/Face:
Pupils: PERRL, conjunctiva pink, Oral Cavity: dry, white tongue. no teeth( "I have dentures but do not wear them") Has NG tube in L nare on continuous suction that appears to be suctioning bile (dark green/brown). Assessment of
Cardiovascular and Respiratory
were normal: Pt has unstable HTN.
Gastrointestina
l
: Diet-NPO abdomen very tender, absent BS X4 Pt IV normal Saline 150 ml/hr. Also received 1000 ml NS bolus because of low urine output
Urinary Reproductive
: Has indwelling catheter secured to RU leg. Low output 15-30 ml/hr.
Neurological/musculoskeletal:
verbal; unclear and soft spoken, Motor skills- seem slow, coordination-labored due to meds. Pt is on complete bed rest. Hand grips and foot pushes/pull are =/strong. Has full ROM no edema noted.
Subjective Data
RBC 3.94 L↓ 4.5-6.0 Helps determine is the pt is anemic, pre surgery lab work
HGB 12.0↓L 14.0-18.0 ↓anemia, kidney disease
HCT 36.2↓L 42.0-51.0 Measures RBC % of total blood volume; ↓indicates anemia, dietary deficiency and/or rheumatoid arthritis. pre/post-surgery lab work
RDW 15.3 H↑ 12.0-15.0 ↑indicate iron deficiency anemia, sickle cell disease, hemolytic anemia and post- hemorrhagic anemia
Na 133↓L 137-145 ↓ CHF, CNS disease, hepatic failure
Creatine 0.6 L↓ 0.7-1.5 ↓in hyperthyroidism, liver disease or inadequate protein intake.
ALB 2.4 L↓ 3.5-5 lack of protein in diet, which causes insufficient healing of wounds
Ca 6.7↓L 8.4-10.2 ↓ indicate possible renal failure and diabetic ketoacidosis
Total Protein L 5.1↓ 6.3-8.2 Measure albumin ( help prevent fluid from leaking out of blood vesels) and globulin ( for the immune system)
Ultrasound was performed to determine picc line placement
Lab results
Orders
Vitals ever 30 minutes
150 mL/ hour NS
NG tube continuous suction
I & O every hour
full assessment every hour
NPO
Wound dressing change once every 12 hrs
Pathophysiology
Lack of hygiene --> caused itching at wound site --> scratching --> infection --> inflammation --> dehiscement of surgical wound.
Dehisccement occurs with a bursting open of a surgical abdominal wound; to avoid: proper nutritional status and risk factors such as malnurishment before surgery, supporting wound during coughing and movements that strain the incision (Venes, 2009).
Ineffective coping related to surgical wound as evidenced by "picking at own wound site" after being told by girlfriend not to do it.
1. teach importance of cleanliness of wound site. Rationale: allow proper healing.
2. Assess skin for further infection Rationale: treating infection early can promote healing
3. Promote good overall hygiene. Rationale: Cleanliness provides healing environment.
4. Recommend good diet habit for proper nutrition and healing. Rationale: good nutrition promotes healing.
5. Explain sign and symptoms of further infection and steps to wound healing. Rationale: Educating the patient allows the patient to be involved in his care.

Ineffective health maintenance related to infection of prior surgery site as evidenced by maggots in wound
1. Stress importance of anti-biotic completion. Rationale: infection can mutates and cause for further infection
2. Teach importance of splinting abdomen for coughing and movement. Rationale: splinting can protect incision site reopening further.
3. Teach proper hygiene before dressing changes and before and after touching surrounding areas of the wound. Rationale: Don't want to spread infection and germs.
4. Teach importance of keeping wound properly dressed. Rationale: to allow proper healing.
5. Unpack, clean and repack wound with prescribe wound packing. Rationale: Wound can heal from inside out instead of closing with infection inside.
Acute Pain related to dehiscement of incision as evidence by crying out in pain and stating pain is 8/10
1. Teach patient to ask for pain medication to keep pain at a manageable level. Rational: getting pain meds before pain is too high can allow for smaller doses and more comfort.
2. Administer prescribed and PRN pain medication in a timely manner.. Rational: Pain medication will alleviate pain
3. Teach patient breathing and relaxation techniques. Rationale: Help relax patient to focus on something other than pain
4. Assess surgery site for further infection and tenderness. Rationale we can determine and treat infection before it worsens.
5. Teach and help patient to splint abdomen when moving and coughing. Rationale splinting can reduce pain
Discharged Planning
1. Discharge to long term rehabilitation facility for long term IV antibiotic treatment
2. Limit activities for next several weeks for recovery or until wound has healed
3. Educate about indicators of infection: abdominal pain, foul smelling discharge
4. Importance of high fiber/high protein/increase fluid intake of at least 2-3L/day.
5. Importance of follow-up care, follow through with doctor appointments and instructions.
6. Importance of cleanliness to wound sites
7. Refer patient to a support group for alcohol and smoking cessation and its health benefits
8. Social Service referral for home living situation

Keep pt from picking at wound for duration of stay at the hospital.
Evaluation: the patient has not touch wound during shift. The goal is met and ongoing
Pt will display knowledge of splinting, while coughing, and verbalize understanding of hand/wound hygiene before leaving the hospital
Evaluation: Pt did spint to cough, but ignored teaching about hand/wound hygiene. The goal is ongoing/ partially met
Patient will verbalize pain 3/10 or an acceptable level within the hour of receiving pain meds.
Patient's stated pain never got below 4/10. The goal was not met, ongoing
Impaired skin integrity related to dehisced wound as evidenced by inflamed redness around wound and under pannis, and penis
To see signs of healing before leaving hospital
1. Clean and dry inflamed skin. Rationale: promotes healing environment
2. Apply creams as prescribed on open areas. Rationale promotes healing
3. Explain importance of cleanliness. Rationale: Educating patient allows him to participate in own care.
4. Assess skin for further irritation. Rationale: Immobility can cause further irritation.
5 Encourage patient to rotate every 2 hrs. Rationale: to avoid pressure ulcers.
Wound was debreided and has a good environment for healing. met.
Objective Data
Noncompliance related to alcohol, tobacco and marijuana use as evidenced by reluctance to change and coming to ED intoxicated.
1. Educate the patient about the adverse effects of smoking and alcohol Rational: Smoking causes HTN and difficulty breathing and alcohol can cause cirrhosis of the liver and bad judgement.
2. Refer pt to support groups for smoking cessation and alcoholism. Rational social support has demonstrated the benefits to help people quit substance abuse.
3. Assess habits that put the patient at risk for substance abuse. Rational Having a plan of action when facing triggers, can help develop better choices.
4. Identify coping strategies for the patient to use instead of substances. Rational; developing coping strategies gives a different outlet to reduce stress.
Patient will verbalize understanding importance of smoking and alcohol cessation before the end of hospital stay.
Not met, patient did not verbalize any interest in habit changing. Ongoing
Other Applicable Nursing Diagnosis
Risk for infection
Dysfunctional gastrointestinal motility
Risk for ineffective renal profusion
Risk decreased cardiac tissue perfusion
Risk for ineffective gastrointestinal profusion
Knowledge deficit
Risk for falls
Smoking Cessation
Ineffective Self Help management
Risk for Powerlessness
Risk for Self-mutilation
Risk for contamination
Risk for impaired liver function
Impaired comfort
social isolation
sleep deprivation
Risk for ineffective activity planning
Impaired physical mobility
risk for imbalanced fluid volume
Bathing self-care deficit
toileting self-care deficit
self-neglect
disturbed body image
Dressing self-care deficit
feeding self-care deficit
Contamination
Delayed surgical recovery
situational low self-esteem
impaired tissue integrity
References
Pagana, Kathleen Deska, PhD, RN. Timothy J Pagana, MD, FACS.
MosbyDiagnostic Labatory Test Reference sixth edition. (2003). St Louis. Mosby Inc. Elsevier Science.
Venes, Donald. M.D., MSJ. (2009). Tabers cyclopedic medical dictionary edition
21. Philadelphia. F. A. Davis Company


Relevant health history
Smoker
Social marijuana user
Occasional alcohol use
history of colon cancer
COPD
uncontrolled HTN
post operative colostomy revision and small bowel revision 9-3-13
Patient was brought to ED by girlfriend complaining of abdominal pain. Girlfriend had stated in ED that she thought his surgical incision was infected and "he was picking and gouging at it for the past couple of days". Upon assessment in the ED, RN found that the wound had dehisced and had fecal matter in it and was full of maggots. Patient was admitted for surgical debreidment of prior surgical site. ED stated to floor nurse that patient was intoxicated upon arrival.
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