MEDSURG NURSING Surgical Wound Dehiscence S SERIES

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MEDSURG NURSING
SERIES
CE Objectives and Evaluation Form appear on page 301.
Surgical Wound Dehiscence
Barbara Hahler
Dehiscence is postoperative wound separation that
involves all layers of the
abdominal wall. It is associated with death, prolonged hospital stays, and incisional herniation (Khan, Naqvi, Irshad,
& Chaudhary, 2004). Because
medical-surgical nurses frequently care for postoperative
patients, awareness of the risk
factors for dehiscence and
measures to prevent dehiscence is important.
Barbara Hahler, MSN, RN, APRN,BC,
CWOCN, is a Clinical Nurse Specialist,
Wound, Ostomy, and Continence
Nursing, St. Vincent Mercy Medical
Center, Toledo, OH.
Note: The author reported no actual or
potential conflict of interest in relation
to this continuing nursing education
article.
296
S
urgical incisions are acute
wounds that activate the healing process. Although it has four
identified stages, wound healing in
reality is a complex, continuous
process. The four stages are hemostasis, inflammation, proliferation,
and maturation (Chin, Diegelmann,
& Schultz, 2005). After a wound is
created, hemorrhage is the initial
response. During hemostasis,
platelets aggregate and degranulate, activating blood clotting.
Once the clot forms, it begins to
break down. As the clot is degrading, the capillaries dilate and
become more permeable. Fluids
flow to the wound site, activating
the complement cascade. The
complement system induces lysis,
the destruction of select cells. This
system helps neutrophils bind to
bacteria, facilitating phagocytosis
and bacterial destruction. Macrophages also are present at the
wound site and help destroy bacteria. They are a source of
cytokines and growth factors that
are essential for normal wound
healing (Chin et al., 2005).
The proliferation phase of
wound healing usually begins 3
days after injury and lasts for several weeks. During this phase, granulation tissue forms in the wound
space. Fibroblasts, which move to
the wound and proliferate, are
responsible for the synthesis of collagen and other connective tissue
development; they are critical for
wound repair. The fibroblasts are
stimulated by growth factors and
converted by cytokines into wound
fibroblasts, which have increased
collagen synthesis behavior. In
sutured incisions, collagen synthesis peaks at day 5. Although granulation tissue is not present, by day
5 it is possible to palpate a healing
ridge just under the intact suture
line (Waldrop & Doughty, 2000).
Epithelialization occurs when granulation is complete. This involves
the migration of epithelial cells
across the skin edges, a process
that begins almost immediately
after surgery and may be complete
in 2-3 days (West & Gimbel, 2000).
At approximately 7 days after
surgery, the maturation phase
begins. This phase lasts for 1 year
or more. Continued collagen
deposition and remodeling contribute to the increased tensile
strength of wounds. Approximately 20% of normal tensile
strength is present at 3 weeks
after surgery. A maximum of 70%80% tensile strength is achieved
after 1 year (Jones, Bale, &
Harding, 2004).
Factors Contributing to
Surgical Wound Dehiscence
Very simply, dehiscence is a
mechanical failure of wound healing. Conditions associated with
increased risk of wound dehiscence are anemia, hypoproteinemia, malnutrition, obesity, malignancy, jaundice, use of steroids,
and diabetes (Sorensen et al.,
2005). Male gender and advanced
age also are associated with
wound disruption. Specific surgical procedures lead to a higher
incidence of wound dehiscence,
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Surgical Wound Dehiscence
including procedures for colon
diseases, peptic ulcer disease,
and
emergency
laparotomy
(Waqar et al., 2005).
Obesity is associated with an
increased infection rate and technical difficulties in closing an
incision (Meeks & Trenhaile,
2005). Steroids given in moderate
doses over a long period of time
seem to decrease the tensile
strength of a healing wound.
Diabetics encounter more healing problems than non-diabetics,
and have a greater risk of developing wound infections. Patients
with diabetes experience less
collagen synthesis and deposition, decreased wound breaking
strength, and impaired leukocyte
function (Waldrop & Doughty,
2000). These differences in
wound repair may occur partially
due to altered insulin levels and
decreased levels of growth factors, such as insulin-like growth
growth factor-1 and transforming
growth factor-beta. Insulin therapy and exogenous growth factors
can increase collagen deposition
and increase tensile strength of
wounds (Waldrop & Doughty,
2000). The jaundiced patient may
experience prolonged healing
and risk for wound dehiscence,
which is related to a pro-inflammatory state resulting from portal and systemic endotoxemia.
Endotoxemia is a result of an
altered bowel barrier function
due to the absence of bile in the
bowel (Koivukangas, Oikarinen,
Risteli, & Haukipuro, 2005).
Malnutrition or radiation
therapy associated with malignancies may lead to wound separation. Radiation may cause
obliterating endarteritis, resulting in decreased blood supply to
the tissues. Patients with malignancies also are more likely to
have a contaminated wound or
abscess
cavity
(Meeks
&
Trenhaile, 2005). Male patients
outnumber women by at least 2
to 1 for wound dehiscence (Hanif
et al., 2000).
MEDSURG Nursing—October 2006—Vol. 15/No. 5
SERIES
Table 1.
Factors Contributing to Wound Dehiscence
▲
▲
▲
▲
▲
▲
▲
▲
▲
▲
▲
Anemia
Malnutrition
Obesity
Malignancy
Jaundice
Use of steroids
Diabetes
Male gender
Advanced age
Wound infection
Increased abdominal pressure (coughing, vomiting, distention, ascites)
Source: CDC, 1999
Local factors also are very
important to consider. For example, infection predisposes a
wound to disruption in the early
postoperative period (Sorensen
et al., 2005). Increased abdominal
pressure also is associated with
wound disruption. This may be
caused by abdominal complications, such as nausea and vomiting, ileus, or a bowel obstruction,
or by pulmonary complications,
such as atelectasis or bronchitis
(Doughty, 2005). Infection and
poor wound healing frequently
are seen in ischemic wounds (see
Table 1). Low blood oxygen content can predispose devitalized
tissue to bacterial colonization
(McGuckin, Goldman, Bolton, &
Salcido, 2003). The persistent
presence of micro-organisms
leads to an increased number of
phagocytes that release proteolytic enzymes, free radicals, and
inflammatory mediators. The
effect of these substances is additional tissue injury and wound
deterioration (Gardner & Frantz,
2004). The inflammatory mediators produce local thrombosis,
resulting in hypoxia. The hypoxia
contributes to further bacteria
growth, establishing a prolonged
inflammatory cycle (Gardner &
Frantz, 2004). Chronic tissue
hypoxia also leads to collagen
with inadequate tensile strength
which contributes to wound
dehiscence (Waldrop & Doughty,
2000).
Interventions to Reduce the
Incidence of Dehiscence
Patients should be instructed
to reduce or eliminate the use of
tobacco products for at least 30
days prior to surgery (Centers for
Disease Control and Prevention
[CDC], 1999). Medications with
an anticoagulant effect, such as
aspirin or nonsteroidal antiinflammatory drugs, also should
be eliminated prior to surgery. A
physician should be contacted to
determine when each medication
should be stopped (Doughty,
2005). These measures will help
promote hemostasis, and improve oxygenation and perfusion
to the tissues. Patients also
should be encouraged to optimize their nutrition prior to
scheduled surgery, especially
their protein intake, to facilitate
wound healing (Doughty, 2005).
Protein is responsible for repair
and synthesis of enzymes
involved in wound healing, cell
replication, and collagen synthesis. The recommended daily protein intake for adults is 0.8g/kg
per day (Posthauer & Thomas,
2004). Patients should be encouraged to increase their intake of
protein-rich foods, such as meat,
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Surgical Wound Dehiscence
fish, legumes, milk, and cheese.
Supplemental drinks also may
provide additional protein. The
Institute for Healthcare Improvement (IHI) also recommends several measures to
reduce surgical site infections.
These include maintaining high
levels of inspired oxygen, avoiding shave prep of the operative
site, controlling serum glucose
levels, preventing hypothermia,
and using prophylactic antibiotics (IHI, 2006).
During the surgical procedure, measures to reduce the risk
of infection are implemented.
Immediately after surgery, the
nurse should maintain patients’
warmth and manage pain
because both measures help to
reduce vasoconstriction (Doughty,
2005; West & Gimbel, 2000).
Hypovolemia is a potent vasocontrictor (West & Gimbel, 2000).
Adequate blood volume will help
maintain tissue oxygen levels.
Tissues that are adequately perfused usually are able to heal
(Waldrop & Doughty, 2000).
Patients who are well perfused
rarely get wound infections, a
contributing factor for wound
dehiscence (West & Gimbel,
2000). Blood volume also should
be maintained by adequate fluid
replacement. Supplemental oxygen should be used to maintain
normal oxygen levels as needed.
Good blood glucose control also
is important for healing (Doughty,
2005). Wound repair in patients
with diabetes mellitus is characterized by decreased collagen
synthesis and deposition and
decreased breaking strength.
Many of the effects of diabetes
mellitus are related to glycemic
control. The management of
patients with diabetes and
wounds should include strict
glycemic control, and measures
to reduce trauma and maximize
tissue perfusion (Doughty, 2005;
Waldrop & Doughty, 2000).
Retention sutures may be
placed to reinforce other clo298
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sures. Retention sutures will
reduce the incidence of wound
dehiscence, but not eliminate it
(Meeks & Trenhaile, 2005). The
CDC recommends that incisions
be covered by sterile dressings
for at least 24-48 hours postoperatively (CDC, 1999). Some surgeons will continue dressings
until epithelialization is complete. The skin’s bacterial barrier
is established once the incision is
epithelialized. The edges of the
incision will be approximated and
no drainage is present. At this
time, dressings are optional.
Wounds heal by primary, secondary, or tertiary intention.
Surgical wounds that are approximated heal by primary intention,
mainly by deposition of connective tissue. Wounds that dehisce
frequently are left to heal by sec-
W
ound dehiscence
frequently occurs
without warning.
ondary intention. These wounds
heal more slowly due to the
amount of connective tissue that
is necessary to fill the wound.
Some surgical wounds initially
are left open; then later the superficial edges are closed, and the
center heals by granulation tissue. These wounds heal by tertiary intention (Waldrop &
Doughty, 2000).
Incisional supports should be
considered for patients at risk for
wound dehiscence, including
those patients who are obese or
malnourished, or have a chronic
cough or chronic steroid use
(Doughty, 2005). Supports include binders for abdominal incisions and surgical bras for
patients with sternal wounds or
large breasts (Doughty, 2005).
The nurse should inspect
incisions each shift for evidence
of separation, and assess for any
signs of infection such as redness, warmth, and edema around
the incision (Gardner & Frantz,
2004). The incision should be palpated for evidence of a healing
ridge (commonly present by day
5). This will feel like an area of
induration beneath the skin
extending to about 1 cm on each
side of the incision (West &
Gimbel, 2000). If the healing ridge
remains absent by day 5 to 9, the
nurse will suspect delayed healing and risk for dehiscence.
Systemic factors, such as malnutrition and elevated glucose level,
that hinder wound healing also
should be evaluated (Gardner &
Frantz, 2004).
Signs of Wound Dehiscence
Wound dehiscence frequently
occurs without warning. The
diagnosis may be obvious if evisceration is present. Frequently
patients report a pulling or ripping sensation, or note that
“something has given way.” In
23%-83% of cases, serosanguinous drainage is present from
the wound prior to the dehiscence (Waqar et al., 2005). Most
dehiscences occur 4-14 days after
surgery, with a mean of 8 days
(Meeks & Trenhaile, 2005; van’t,
De Vos Van Steenwijk, Bonjer,
Steyerberg, & Jeekel, 2004).
Diagnosis can be made based on
clinical presentation and wound
inspection in the majority of
cases. Imaging studies, such as
ultrasound, computerized tomography scan, or MRI, can be used if
the diagnosis is unclear (Meeks &
Trenhaile, 2005).
Immediate Nursing
Interventions
If wound dehiscence is
detected, the nurse will return
the patient to bed and lower the
head of the bed to no higher than
20 degrees (Moz, 2004). Evisceration also may have occurred
and measures to reduce abdominal pressure should be implemented. The patient should bend
the knees and avoid coughing to
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Surgical Wound Dehiscence
reduce abdominal pressure.
Sterile gauze or towels soaked in
sterile saline should be placed
over the wound or any exposed
bowel. The nurse should not try
to push any viscera back into
abdomen. The color of the tissue
and any exposed bowel should be
assessed, and the supervisor and
surgeon notified of the change in
the patient’s condition. The nurse
should assess the patient’s vital
signs and oxygen saturation
every 15 minutes. The patient
should be reassured regarding
his or her condition. Pain should
be assessed and managed appropriately. An intravenous line
should be present in case the
patient needs immediate surgery.
The patient should have nothing
by mouth. It is important for the
nurse to stay with the patient to
monitor vital signs and monitor
for shock until the patient is seen
by a physician (McConnell, 1998;
Moz, 2004). After a surgeon has
examined the wound, an abdominal binder may be ordered to support the abdomen if surgery is
not indicated (Meeks & Trenhaile,
2005)
Wound Management
The dehisced wound is managed the same as any other open
wound if immediate surgical closure is not done. Topical therapy
should include measures to maintain a moist environment, reduce
infection, manage pain, and eliminate all necrotic material
(Doughty, 2005). Hydrogel or gel
dressings are water-based or
glycerin-based products available
as amorphous gels, gauze impregnated with gel, or sheet gels.
Hydrogels help maintain a moist
wound environment for dry
wounds, and they promote granulation and epithelialization. After
application, they are covered
with a dry dressing, or a dry
dressing and transparent film
(Hess, 2002). Alginate dressings
can be effective for wounds with
a moderate-to-large amount of
MEDSURG Nursing—October 2006—Vol. 15/No. 5
SERIES
Table 2.
Wound Care Products
Dressing
Drainage Absorbed
Function
Hydrogel
Minimal
Hydrate wound
Alginate
Moderate to large
Absorb drainage; promote
moist wound healing
Silver dressings
Minimal to large
Reduce bacterial load of
wound; some absorption of
drainage
Collagen dressings
Minimal to large
Provide collagen to wound
bed
Negative pressure
wound therapy
Minimal to large
Stimulate granulation tissue;
absorb drainage
Source: Hess, 2002
drainage. Alginates, which are
derived from brown seaweed,
consist of woven fibers formed
into sheets or ropes. When used
to fill a wound, alginates absorb
drainage and form a soft gel.
Some formulations can absorb up
to 20 times their weight in fluid.
They can be covered with secondary gauze dressing or a transparent film dressing (Hess, 2002).
Silver is a broad-based
antimicrobial agent that controls
bacteria, mold, and yeast. Some
silver agents control methicillinresistant staphylococcus aureus
(MRSA) and vancomycin-resistant enterococci (VRE) when at
appropriate concentrations. Silver
inhibits cellular respiration, denatures nucleic acids, and alters cell
membrane permeability (Warriner
& Burrell, 2005). Silver dressings
come in several formulations,
including sheets, combined with
alginates and foams, as well as
wound fillers. Some silver-impregnated dressings are meant to be
worn for up to several days.
These dressings are usually covered with a dry gauze secondary
dressing. Because several types
of silver dressings are available, it
is imperative to read the product
insert carefully prior to use of
these dressings.
Collagen dressings encourage
the deposition and organization
of collagen in the wound bed
(Hess & Kirsner, 2003). These
dressings are available in sheets,
pads, gels, and particles. Collagen
dressings may be used as the primary dressing for dehisced
wounds with minimal-to-heavy
exudates. A secondary dressing
will be required (Hess, 2002).
Negative pressure wound
therapy may be used for fullthickness dehisced wounds with
moderate-to-heavy drainage. Negative pressure is applied to a special dressing that is placed in the
wound bed. Interstitial fluid is
removed from the wound, circulation increased, and more rapid
formation of granulation tissue
occurs (Hess, 2002) (see Table 2).
Summary
Despite advances in preoperative care, the rate of surgical
wound dehiscence has not
decreased in recent years; 1%-3%
of patients experience wound
dehiscence. A nursing goal for the
postoperative patient is always
prevention of wound dehiscence.
Recognition of risk factors is
essential. For example, older
males with ascites are at very
high risk. Prevention of wound
infection and mechanical stress
on the incision are important.
Management of dehisced
wounds may include immediate
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Surgical Wound Dehiscence
N
urses need to ensure adequate nutrition and
reduced tension on the abdomen, and implement
measures to prevent incisional infections.
surgery if bowel is protruding
from the wound. If surgery is not
needed, management is essentially the same as that of any other
wound through maintenance of a
moist wound environment, reduction of bioburden and pain, and
promotion of granulation tissue.
Mortality rates associated with
dehiscence have been reported
between 14% and 50% (Hanif et
al., 2000; Waqar et al., 2005). One
of the complications (morbidity)
of dehisced wounds is an incisional hernia, which develops in
an estimated 43% of patients
(van’t et al., 2004). Researchers
followed 126 patients who had
wound dehiscence repair for a
mean of 37 months and found
that 31% of the hernias were diagnosed more than 2 years postoperatively. Nurses need to ensure
adequate nutrition and reduced
tension on the abdomen, and
implement measures to prevent
incisional infections. ■
References
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