السبت، 25 أغسطس 2018

108-Dehiscence

About
Incisional edges start to separate, edges are not approximated. Usually occurs as a result of incisional pulling, straining, or increased stress at incision site.
Assess
Incision edges and approximation, obesity, splinting with coughing, surrounding skin
Complications
Evisceration, scarring, infection
Diagnosis
  • Impaired skin integrity related to incision trauma
  • Pain related to incisional trauma
  • Risk for infection
Goals
  • The client's incision will heal with edges well approximated.
  • The client will remain free from infection.
  • The client will identify strategies to prevent incision stress.
Interventions
  • Assess incisions frequently, noting any signs of stress, tension on sutures or staples.
  • Teach client preventative strategies such as using splinting with coughing and deep breathing.
  • Apply abdominal binder for high risk ( obese) clients as indicated by physician.
  • Notify physician immediately if excess bleeding, drainage, swelling, or redness surrounding incision.
  • Notify physician if edges start to separate from incision site or if absent staples or sutures along incision line.
  • Cover any areas of separation with sterile gauze to prevent infection.

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