how do you assess for wound dehiscence?

silentRN · Dec 7, 2010

well, you can just lift the dressing up on one side. Then, when you are done assessing just put the dressing down and re-tape it or reinforce it if saturated.

roser13, ASN, RN · Dec 7, 2010

What do you mean you are "not allowed" to touch the dressing? Is that an MD order? It would be impossible to assess a wound without visualizing it.

PostOpPrincess, BSN, RN · Dec 7, 2010

Someone needs to look at it, and do something about it.

allnurses Guide · Dec 7, 2010

Yeah, if the patient said that they felt something tear or pop or whatever, I'd take the dressing off and look at it anway, and then tape it back down if it looks OK.

Then DOCUMENT your findings, and what the patient said. If the wound is dehisced, you need to let the surgeon know ASAP. He may yell at you for taking the dressing off but you know what? Like JoPACU said, you're the nurse with this patient, and someone needed to look at that incision. If you DOCUMENT (that's the magic word!!), you aren't going to get in any trouble. You don't work for the doctor.

NewlyGradBSN · Dec 7, 2010

I am currently a trainee and I do not know where do I stand. I have so much to learn. I referred what happened to her Attending Physician. I asked him if we should check underneath the dressing and all he said was that it was not possible for the site to open. I also referred it to my senior and they opted to give her pain reliever. I really wanted to check underneath the dressing but all I did was assess the dressing for any stain or drainage. I also palpated for any bumps. In that hospital, the doctor's are the ones the handle the dressings. I never saw a nurse remove a dressing to check the post op site which I know should be the practice. That's why I assessed the site without removing the dressing. I referred it to my senior and to her doctor. I am now worried or just paranoid. If there was dehiscence, there should be stain on the dressing right? I really wanted to check the site but I am just a trainee so I second guessed myself:( So, what I did was refer.

brownbook · Dec 7, 2010

DO NOT REMOVE A WOUND DRESSING.

The safest way to deal with any wound problem is to cover the existing dressing with more dressing, tape, gauze, whatever you have at hand. I wouldn't even peek!!!! It doesn't matter if you think it dehisced, or it is bleeding more that you think is reasonable, or the patient says it popped.

Then call the surgeon, or ask your charge nurse or more experienced nurse for help.

Most surgeons do not like their dressings removed, just reinforced.

If it is definitely actually dehisced that is a whole other nursing discussion. This is just dealing when you "think" something is wrong.

(My spell check doesn't like how I spell dehisced, am I spelling it correctly? My dictionary is useless!!)

silentRN · Dec 7, 2010

Well, a nurse is a coordinator of care. I say open that dang dressing up and take a peak. The only way you will ever know is if you lay your eyes on it and assess it. There is no harm in just lifting up the 4x4 dressing and sneaking a peak underneath. There's no reason to be paranoid. They just don't want the dressings touched because they want to see the drainage themselves the next morning. I wouldn't be paranoid if I were you. There is enough unnecessary stress added to nurses daily that don't need to be there, and a lot of the stress is caused by ourselves over little things.

nurse2033, MSN, RN · Dec 8, 2010

We need one of those TSA scanners at the bedside, that way we could look through the bandages without touching

Sarah010101 · Dec 8, 2010

Do you mean such as ortho dressings? like.. TKA, THA?... we dont remove those or lift at all where I work... I need an order to change it at all. Same as the trach dressings.

I always get kind of confused on whether the wound is dehiscing or if that was what the suture line actually looked like to begin with (some patients do not have perfect incisions... I have seen one where the skin is gaping open when removing alternate staples, but have been told that the sutures are still intact)... this confuses me. If a would is dehisced will it be gaping open and very noticable?

nurse2033, MSN, RN · Dec 8, 2010

DO NOT REMOVE A WOUND DRESSING.
The safest way to deal with any wound problem is to cover the existing dressing with more dressing, tape, gauze, whatever you have at hand. I wouldn't even peek!!!! It doesn't matter if you think it dehisced, or it is bleeding more that you think is reasonable, or the patient says it popped.
Then call the surgeon, or ask your charge nurse or more experienced nurse for help.
Most surgeons do not like their dressings removed, just reinforced.
If it is definitely actually dehisced that is a whole other nursing discussion. This is just dealing when you "think" something is wrong.
(My spell check doesn't like how I spell dehisced, am I spelling it correctly? My dictionary is useless!!)

Sorry but my jaw dropped here, but are you kidding? If you suspect something is wrong you assess. Looking under a dressing is simply good practice. Obviously you do it in a way that is safe . A dressing is not some sacrosanct domain that only ordained surgeons may approach.

brownbook · Dec 8, 2010

Okay, pick up your jaw. Although I honestly don't know that even if I thought a fresh post-op wound dehisced that I would peek. So much is done laparoscopically these days it hardly is an issue, thankfully!

Definitely if it was bleeding a lot I would not peek. I would reinforce!!!!

A lot would have to do with how old the incision is. Which the original question never mentioned. The newer the incision, a few hours post-op, the less likely I would be to peek. An incision a few days old would change my intervention.

The original question was written so vaguely and confirmed in her reply that she is a new trainee. I would strongly advise a new trainee trainee not to peek under any surgical dressing.

I still stand by my opinion. But this is coming from fresh post-op patients, not someone on the floor the next day or two.