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Provide Local Wound Care


a. Post Surgical Wound Care

Table 2: Post-surgical Care

Dressings
  • Initial dressing applied during surgery should remain on for 48 hours (reinforce as necessary for breakthrough drainage).
  • Use an aseptic non-touch technique for changing or removing surgical wound dressings
  • Dressing should be chosen on the basis of cost-effectiveness, properties of dressing and patient/caregiver preference
  • Provide moist wound healing to promote growth of granulation tissue, prevent prolonged inflammation and protect from trauma, exudate and infection
  • Provides thermal regulation
Primary intention
  • Usually only require dry, sterile cover dressing for 24-48 hours for protection
  • Should re-epithelize within 2-3 days
  • Palpate healing ridge approximately 5 days

Secondary intention
  • Interactive products should be used.
  • Require moist healing environment while preventing peri-wound maceration or desiccation.
  • Dressing should prevent bacteria from entering wound
Exudating wounds
  • Dressing choice should maintain moisture while wicking moisture away from peri-wound skin to prevent maceration
  • Decreased pain when removed
  • Calcium alginate (best for bleeding wounds)
  • Hydro-fiber
  • Foam dressing
  • Exudate absorbers
  • Secondary dressing may be used
  • Periwound may benefit from barrier film/hydrocolloid
  • Negative pressure wound therapy (NPWT) may be indicated
Pouching
  • Consider if wound exudates >25 ml/day or dressing requires changing more than 3-4 times/day
  • Suggest referral to Enterostomal Therapist (ET) or Wound Care Specialist
Dry wounds
  • Prevents growth of granulation tissue and re-epithelization
  • May benefit from hydrogel, hydrocolloid, non-adherent mesh or transparent film/dressings
Cleansing
  • Use sterile saline up to 48 hours post-op
  • Patients can usually shower after 48 hours
  • Use tap water after 48 hours if incision has dehisced or been surgically opened
Topical Antimicrobial Agents
  • If healing in timely manner, topical agents not required
  • Use appropriate interactive dressing
  • Refer to Wound Care Specialist as required
Healing by primary intention - Do NOT use ANY
 
Healing by secondary intention - Do NOT use Eusol and gauze, moist gauze or mercuric antiseptic solutions
 
Debridement

DO NOT USE - EUSOL/DEXTRANOMER OR ENZYMATIC TREATMENTS FOR DEBRIDEMENT ON SURGICAL WOUNDS

Autolytic debridement - Promote where appropriate

Mechanical debridement - Irrigation – safe pressures (8-15 psi’s) will help remove loose necrotic tissue. Ensure that majority of irrigation solution is recovered

Conservative sharp debridement – Must be within scope of practice. Provide analgesia prior to procedure as necessary

Maggot therapy – Not commonly used in Canada
 

Table 2: Post-surgical Care (adapted)1 2 3 4

Antibiotics are generally given preoperatively or inter-operatively for patients having clean surgery involving placement of implant or prosthetic, clean-contaminated surgery or contaminated surgery.5

Clinical Outcomes of Surgical Site Infections6
  • Poor scars (cosmetically unacceptable, spreading, hypertrophic or keloid)
  • Persistent pain
  • Itching
  • Restriction of movement especially over joints
  • Impact on social well-being affected
Additional costs of surgical site infections
  • Re-operation
  • Extra nursing care
  • Extra interventions
  • Drug treatments
  • Loss of productivity
  • Patient dissatisfaction
  • Litigation
  • Decreased quality of life
Microorganisms that cause infection7
  • Staphylococcus aureus (most commonly found)
  • Colorectal surgery – enterobacteriaceae and anaerobes
  • Prosthetic surgery/presence of foreign body – staphylococcus epideremidis
  • Number of microorganisms required to cause infection is lower
How do microorganisms come in contact with wound8
  • Endogenous infection (from patient)
  • Microorganisms from instruments or operating room environment
  • Contamination from environment (in trauma wound)
  • Microorganisms gain access to wound after surgery
Practices to prevent surgical site infection9
  • Handwashing
  • Remove microorganisms that normally colonize the skin
  • Prevent the multiplication of microorganisms at the operative site (use of prophylactic antibiotics)
  • Enhance patient’s defences against infection by minimizing tissue damage and maintaining normothermia
  • Preventing access of microorganisms into the incision postoperatively by use of wound dressings

b. Signs and symptoms of Cellulitis10 11

  • Cellulitis is a spreading bacterial infection of the dermis and subcutaneous tissues, where the edge of the erythema may be well-defined or more diffuse and typically spreads rapidly
  • Systemic upset with fever and malaise occurs in most cases, and may be present before the localising signs such as the local symptoms seen with STONEES
  • Lower leg cellulitis can be extremely serious with long-term morbidity, including lower leg edema. It requires prompt recognition by health care providers and appropriate interventions
  • Note that lower leg cellulitis usually affects only one leg, not both. If both legs are affected, it is likely venous dermatitis or allergic contact dermatitis, but this does not mean that it could never be cellulitis in both legs
     

c. Determining Goals for Local Treatment for Surgical Wounds12

Level A, B and C: RNAO’s Interpretation of Evidence 


 

Healable Wounds: Have sufficient vascular supply, underlying cause can be corrected & health can be optimized
 
Goal: Principles of wound bed preparation and moist wound healing: debridement,bacterial balance, exudate control, protect peri-wound skin
 
Maintenance Wounds:
Have healing potential, but various patient factors are compromising wound healing at this time
 
Goal: Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control and protect peri-wound skin. Avoid higher cost advanced wound treatments until factors compromising wound healing are resolved. Focus on quality of life issues, exudate and odour management
 
Non-healable/Palliative wounds:
Has no ability to heal due to untreatable causes such as insufficient vascular supply, terminal disease or end-of-life
 
Goal: Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues.

Calculating Current Percentage of Healing Since Admission
 
V(Initial) – V (Current) X 100 =________ % reduction in volume
                                        V (Initial)
(V = Volume of wound calculated as Longest Length x Perpendicular Widest Width x Depth straight in)
(Adapted from Sussman and Bates-Jensen 2007)
 
‘Closed’ vs ‘Healed’
  • Closed: Skin intact, underlying tissue or structures are not visible
  • Healed: Wound has been closed for a 2 year time period allowing
                  for collagen re-modelling from type 3 to type 1
These terms are often mistakenly used interchangeably

Understand and teach the difference!

Treatment Plan
  • Documentation and communication between all healthcare team
  • Wound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable)
  • Arrange for physician/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendations
  • Maintain original dressing x 48 hours after surgery (reinforce dressing prior to this if necessary)
  • Provide pressure redistribution (support surfaces) for sleep, seating and use of medical devices
  • Debridement/reduction by qualified professional
  • Ensure appropriate skin care
  • Identify any potential barriers to wound treatment plan
  • Consider required referals and further follow-up with previous professional referrals
  • Consider compression if venous insufficiency/edema present and if ABPI/TBPI is within safe range
  • Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart)
  • Advanced therapies e.g. Negative Pressure Wound Therapy (NPWT), Electric Stimulation and Hyperbaric Oxygen Therapy might be considered

Healable/Maintenance Treatment Plan
  • Correction of the underlying disease process if possible
  • Collaborative agreement between the physician, nurses, team, and the client regarding setting goals about the “healability” of the wound
  • Pain control
  • Debridement can lead to wound enlargement, spread infection or lead to further necrosis
  • If there is objective evidence that wound is healable, conservative sharp, surgical, mechanical, or autolytic debridement is recommended
  • Avoid ‘tourniquet affect’ when securing dressings
  • Avoid nicotine and caffeine use
  • Optimize nutrition
Palliative or Non-healable Plan
  • NO DEBRIDEMENT to be performed
  • Minimize risk of infection with use of providone-iodine or chlorhexidine
  • Health teaching regarding signs and symptoms of an infection to client and caregiver
  • Care should be used when removing tape to prevent trauma
  • Avoid ‘tourniquet affect’ when securing dressings
  • Pain Control
Compression Use
  • Only to be used if there is objective evidence that arterial supply is sufficient for healing
  • Used only under close supervision of very experienced wound care specialists for mixed (venous and arterial) etiologies
  • Mild compression may be used after by-pass surgery to prevent edema (only with surgeon’s order)
  • Should be removed immediately if pain develops
Initatition of compression therapy requires a lower leg assessment to be completed, ABPIs/TBPIs to be determined and results evaluated in addition to physician/NP order
 

d. Utilize Product Picker from Canadian Association of Wound Care (CAWC)

Product Picker for Classification of Dressing Products Each organization may use the PDF Fillable CAWC Product Picker to list the products available within their organization
   
When trying a new product, allow 2 weeks to assess effectiveness unless adverse effect noted.
 

e. Patient Education on Skin Care13

Skin care is a vital element to promote wound healing.

The following information is provided to patients as recommended practices:
  • Avoid harsh soaps or highly perfumed soaps
  • Soothe any local skin irritation with a moisturizing cream
  • Avoid creams with perfumes and lanolin, as these products increase the risk of dermatitis
  • Monitor skin for potential reactions, and if present, contact your care provider
  • Discuss long-term use of steroids with your care provider
  • Avoid the use of adhesive products

f. Adjunctive Therapies14

Consider Multi-disciplinary referrals for adjunctive therapy. Adjunctive therapy refers to additional treatment used together with the primary treatment to achieve the outcome of the primary treatment. These should be limited to healable wounds.

Negative Pressure Wound Therapy
  • Removes exudate
  • Reduces peri-wound edema
  • Increases local microvascular blood flow
  • Promotes formation of granulation tissue
  • Reduces complexity of wound
  • Supports moist wound bed environment
  • Enhances circulation
  • Increases oxygenation to compromised tissue
Indications for NPWT
  • Wound dehiscence or wound with potential to heal
  • Stabilization of graft
  • Incision at risk for dehiscence
  • Appears to decrease surgical site infection rates after invasive treatment of lower limb trauma
  • Less effective with multiple comorbidities
Contraindications for NPWT
  • Unexplored fistula
  • Necrotic tissue
  • Untreated osteomyelitis  
  • Malignancy within wound
Precautions
  • Must be free of active UNTREATED infection
  • Wound bed must NOT involve fistulas to internal organs or body cavities
  • Caution with anticoagulants
  • Hypergranulation and wound odour may occur with patients over the age of 65
  • Discontinue if patient complains of pain
  • Use systemic antibiotics with NPWT to treat infections
Electrical Stimulation
  • Increases blood flow
  • Increases tissue oxygenation
  • Angiogenesis
  • Increases tensile strength of wound
  • Decreases pain
  • Decreases diabetic peripheral neuropathic pain
  • Increases cell proliferation and protein synthesis
Contraindications to Electrical Stimulation
  • Osteomyelitis
  • Demand pacemakers
  • Wounds with heavy metal residues
  • Pregnancy
  • Electrode placement over carotid sinus or tangential  to heart or over laryngeal musculature
  • Malignancy
  • History of dysrhythmia
Hyperbaric Oxygen Therapy (HBOT)
  • Angiogenesis
  • Collagen synthesis
  • Osteoclastic activity
  • Releases growth factor
  • Increases oxygen diffusion in plasma and local tissues
  • Leukocyte-killing ability
  • Increases effectiveness of antibiotics
  • Decreases edema
Indications for HBOT
  • Compromised skin grafts and flaps
  • Hypoxic wounds
Precuations for HBOT
  • Claustrophobia
  • Anxiety

Provide Organizational Support
 

  1. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  2. Network, Scottish Intercollegiate Guidelines. Postoperative Management of Adults. 2004.
  3. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  4. Okan D, Woo K, Ayello EA, et al. The Role of Moisture Balance in Wound Healing. s.l. : Advanced Skin Wound Care, 2007.
  5. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  6. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  7. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  8. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  9. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
  10. Increased bacterial burden and infection: The Story of NERDS and STONEES. Sibbald R G, Woo K, Ayello E. 8, s.l. : Advanced Skin and Wound Care, 2006, Vol. 19.
  11. M, Eagle. Understanding cellutlitis of the lower limb. s.l. : Wound Essentials, 2007.
  12. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
  13. Ontario, Registered Nurses Association of. Learning Package: Assessment and Management of Venous Leg Ulcers. Toronto : s.n., June 2006.
  14. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.

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