surgeon found the colon Evisceration before me

[SNB1014, RN]

i floated to icu yesterday from pcu. they try to give us more "stable" pts, aka not vented, works for me.

anyways, so this morbidly obese, aucte renal failure, diabetic, htn, whole sha-bang pt was mine. heres the backstory: apparently she hadn't had a BM in over two weeks when she came in. her colon ruptured, fecal peritonitis ensued. she ha"d been extubated about 12 hrs before i had her. well she now had an illeostomy and mucousal drainage site. her midline abdominal wound was about 8" long and about 6" deep and at the widest part it was about 5" wide. they had rentention sutures in and the wound was packed wet-dry BID and covered with an abdominal dressing. they had changed the dressing on night shift at about 3am, so i was going to have a go at the dressing around 3pm. her bp was high around 170/70 despite hydralzine, not much pee at all and her K was 5.1, Ca was 7.6. i had called, gotten supplements and orders from the attending regarding this. she had some wheezing noted. orders given for that. she had complained earlier in the am about some substernal chest pain and coughed on and off during the morning.

anyways, so the surgeon pops in and is like hey how is her wound, I said, well i was just about to change is (it was almost 3pm), i already premedicated her, lets go in together.

the abdominal dresisng was still intact, no drainage, etc. well as the surgeon is unraveling the packed gauze, he is chatty, friendly and then STOPS talking, steps back and sighs. i take a peak around him to see a HUGE bulge, size of a baseball. it was her colon. it was still pink and moist. he stays quiet then says "um yeah, i need her in the OR immediately. go get the consents and cover her up for now"

i felt so terrible for this lady. the wound was good, according to night shift and the dressing change wasn't due yet. when the surgeon took off the abdominal pad, all you see it gauze. it wasnt until all the gauze it taken out that you see this huge intestine bulging.

what were some of the possible s/s of complications i could have missed?

I asked the surgeon how this could of happened and he said " well im not suprised, i couldnt even close the wound the first time and i put extra rentention sutures in b/c i had a feeling. but she has all this DM2, htn, kidney issues, and she is just morbidly obese. it probably happened because she was coughing after being extubated...until i undid the dressing, my plan today was to take the ng tube out and start some clear liquids, i guess we are back to square zero here" etc.

URGHHHH.

i *thought* that unless i suspect something new, as in gross change of status, reports of increased pain, increased soiling/bleeding from wound dressing, i should just leave the dressing alone until it is my turn to change the whole thing? Am i wrong? Where in my abdominal assessment or general head to toe would i have picked up on this?

[Biffbradford]

Nah, I doubt it. It happens. At least he was cool about it. Might have popped a stitch or two when coughing. Nice tip from him about having a hard time closing. Useful info like that usually stays in the O.R. so how would you even guess? Off to the O.R. ... NEXT!

[meandragonbrett]

Nothing you did. Not to worry. It just happens.

Did she have an abdominal binder on? She probably should have. It sounds based on the way that you describe that she was still open down the fascia and that you were packing the subcut tissues.

[SNB1014, RN]

she *now* has an abdominal binder when she came out of OR. the CRNA said that when they were putting the binder on a suture popped again. the surgeon said he told the daughter it could very well happen again.

it just sucks. you wonder like, "ohhh sugar! how long was that there? is THAT why she was a little tachycardic? was the epigastric pain surgical pain or was that when it popped?"

and yes, luckily the surgeon was cool to me about it.

[eatmysoxRN, ASN, RN]

It really doesn't sound like anything you did or didn't do. You wouldn't want to change that dressing to look for changes everytime she coughed. Sounds like a bad situation. Maybe the binder will help.

[tcvnurse, BSN, RN]

You didn't miss anything. Something this stuff just happens