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UNIT 4 Supporting Physiological Function
of hemorrhage (both internal and external bleeding) is greatest in the first 24 to 48 hours after surgery or injury. Internal Hemorrhage Swelling of the affected body part, pain, and changes in vital signs (i.e., decreased blood pressure, elevated pulse) may indicate internal bleeding. In this chapter, the term internal bleeding refers to a hematoma, a red-blue collection of blood under the skin, which forms because of bleeding that cannot escape to the surface. A large hematoma causes pressure on surrounding tissues. If the hematoma is located near a major artery or vein, it may impede blood flow. External Hemorrhage External hemorrhage is rel- atively easy to recognize. You will see bloody drainage on the dressings and in the wound drainage devices. When there is a brisk hemorrhage, blood often pools as the dressings become saturated. To be sure that you are aware of the full extent of the bleeding, remember to look underneath the patient. Infection Early recognition of infection is crucial to wound management. ■ Suspect infection if a wound fails to heal . Other symptoms suggesting infection are: ■ Localized swelling ■ Redness ■ Heat ■ Pain ■ Fever (temperatures higher than 38°C [100.4°F]) ■ Foul-smelling or purulent drainage ■ A change in the color of drainage ■ In a contaminated or traumatic wound, the symp- toms are likely to occur within 2 to 3 days. ■ In a clean surgical wound, you will usually not see signs and symptoms of an infection until the fourth or fifth postoperative day. Distinction between infection in the superficial tis- sues and those in deeper compartments is important for guiding treatment plans. Typically, superficial infec- tions respond to topical antimicrobials; deep infection requires the use of systemic antimicrobial agents. For identifying superficial infection, think of the acro- nym NERDS: ■ “N onhealing wounds ■ E xudative wounds ■ R ed and bleeding wound surface granulation tissue ■ D ebris (yellow or black necrotic tissue) on the wound surface ■ S mell or unpleasant odor from the wound” (Sibbald et al., 2006, p. 452) For deep infection, consider the acronym STONES: ■ “S ize is bigger ■ T emperature increased ■ O s [probe to or exposed bone]
■ N ew or satellite areas of breakdown ■ E xudate, erythema, edema ■ S mell” (Sibbald et al., 2006, p. 452).
Dehiscence Rupture (separation) of one or more layers of a wound is called dehiscence (Fig. 32-7). Wound dehiscence is most likely to occur in the inflammatory phase of healing, before large amounts of collagen have been deposited in the wound to strengthen it. An increased risk of dehis- cence occurs from incisions that begin draining within 5 to 7 days after surgery. Common causes of wound dehiscence are: ■ Poor nutritional status ■ Inadequate closure of the muscles ■ Wound infection ■ Increased tension on the suture line (e.g., coughing, lifting an object) ■ Obesity because fatty tissue does not heal readily, and increased tissue mass puts additional strain on the suture line. Dehiscence is usually associated with abdominal wounds. Patients often report feeling a “pop” or tear, especially with sudden straining from coughing, vom- iting, changing positions in bed, or standing. Usually, there is an immediate increase in serosanguineous drainage. Nursing interventions include the following: ■ Maintaining bedrest with the head of the bed elevated at 20° and the knees flexed ■ Applying a binder, if necessary, to prevent evisceration ■ Notifying the provider of the dehiscence immediately Evisceration Evisceration is the total separation of the layers of a wound with internal viscera protruding through the incision (Fig. 32-8). Key Point: This rare complication is a surgical emergency. ■ Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent
Muscle (intact)
Adipose tissue
FIGURE 32-7 Dehiscence is the separation of one or more layers of a wound. It is most common in the inflammatory phase of healing.
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