About
Incisional edges separate, edges are not approximated and underlying fascia and organs start to protrude from incision site. Usually occurs as a result of incisional pulling, straining, or increased stress at incision site. Emergent situation that requires immediate intervention to prevent tissue or organ death.
Assess
Incision edges and approximation, obesity, splinting with coughing, surrounding skin
Complications
Scarring, open wound, organ trauma and ischemia, infection, sepsis, peritonitis
Diagnosis
- Risk for infection
- Impaired skin integrity related to incision trauma
- Pain related to incisional trauma
Goals
- The client's incision will heal by secondary intention.
- The client will remain free from infection.
- The client will demonstrate dressing changes using aseptic technique.
- The client will be able to state signs and symptoms of infection and when to receive follow-up by health care provider.
- The client will identify strategies to prevent incision stress.
Interventions
- Cover open area and protruding organs immediately with saline soaked sterile gauze.
- Notify surgeon Immediately and prepare client for surgery to close wound.
- 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.
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