how do you assess for wound dehiscence?

[NewlyGradBSN]

how do you do it when you are not allowed to touch the dressing covering the site? there is no stain on the dressing though but the patient verbalized that she felt something open up. I told the doctor and he also assessed...so back to my question. sorry for bothering anyone.

[roser13, ASN, RN]

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.

My jaw joined yours on the floor. If my patient complained of "something opening up," you can bet I would be safely assessing the wound, visually.

I think given the OP's own description of herself as a "trainee," that we're dealing with orientation issues, rather than MD orders to not touch the dressing. There's no doubt in my mind that most experienced nurses would take steps to properly assess the situation.

[leslie :-D]

i can't imagine a pt telling me this, and NOT looking.

let's say a wound did dehisce (sp) and the dsg was reinforced.

by the time surgeon comes to look, an infection or bleed has set in...

and causes the pt substantial and further injury.

when it gets to court, i just cannot see myself telling a judge et al, that i wasn't allowed to assess, and that is my reason for the delay in treatment.

nope...darned tootin' i'm going to look, and note my findings.

but as someone new op, i understand your hesitation.

leslie

[CrunchRN, ADN, RN]

I think the nurse may be british or australian and nurses scope can be very different in those places vs. USA......

[tainted1972, ASN, RN]

If I truly wasn't allowed to remove a dressing and I suspected a dehiscence. I bet I would find that dressing not intact when I was assessing the patient. :)

[XB9S, BSN, MSN, EdD, RN, APN]

I think the nurse may be british or australian and nurses scope can be very different in those places vs. USA......

In the UK if we suspected a problem with a wound the dressing would be removed.

[al7139, ASN, RN]

Hi all,

Here is my opinion:

If I have a fresh post-op patient, then the site needs to be assessed. Yes most surgeons prefer to do the dressing changes themselves, but unless it is a dressing that is wrapped around an extremity (such as a fracture or a TKR), it is possible to uncover the incision to assess it. There are rarely orders not to touch the dressing (with the POSSIBLE exception of a pressure dressing, and they are usually only for a short period of time). If a patient reports any unusual sensations, such as feeling it give way, or sudden pain, etc., then I will look under the dressing, and report to the surgeron my assessment and the patients concerns. Also remember it is possible for the surface sutures or staples to stay closed, while the inner layers can open up (not a good thing), so it is important to always report your findings to the surgeon.

Also if I have to continuously reinforce a dressing due to heavy bleeding, I call the surgeon because this is not normal either.

I also make sure I document everything from my assessment to my phone call to the doc, and their orders (or lack of), and I reassess and document that as well. I also will let my charge know what is going on. I would rather look at an incision, and have everything be OK than not look, and have there be a problem, because I was scared to get fussed at by a doc. And, most docs, will not get upset at you doing your job, and if they do, thats on them, just let it roll off your back.

Amy