Wound Care: Moving Toward HealingPage 9 of 13

7. Surgical Wounds

According to the CDC, a surgical site infection typically occurs less than 30 days after the procedure. Each year, 1 in 20 surgical patients experience a surgical site infection. Patients with surgical site infection (SSI) have a significant risk of morbidity and mortality related to the infection. The most common early sign of infection is an increase in wound drainage. This is seen between 10 and 14 days post operatively (Molnlycke , 2016). The most common comorbidities implicated with a SSI are diabetes and obesity.

With diabetic patients, post operative glucose control and compliance greatly impacts wound healing rates. A glucose level over 110 is the biggest risk factor associated with SSI (Molnlycke, 2016). Educate the patient and caregiver that slight redness around the wound edges can be expected for the first few days after surgery. However, they should call the physician immediately if they see redness spreading greater than 2 cm around the incision site or an increase in pain, purulent drainage, or swelling (Moinlycke, 2016).

The original surgical dressing is generally first changed by the surgeon, and this should occur in the acute care setting. Surgical incisions are recommended to be covered with a sterile dressing for the first 24 to 48 hours post operatively (Bryan & Nix, 2015). A post operative wound dressing that allows for early bath or shower encourages early mobilization, an important post operative goal. Post operative patient and caregiver education focuses on proper dressing changes, wound cleansing, and instructions on infection prevention.

The area must be assessed with each visit for clean, dry, intact suture line and no evidence of dehiscence or infection. Wound dehiscence can be noted if the wound edges fail to join or the integrity of the sutures is compromised. This should be reported to the physician as soon as possible to prevent further complications. The patient, family and caregivers must be educated during the visit on signs and symptoms of infection and the importance of hand hygiene to assist in ideal wound healing without infection.

Signs and symptoms of infection include an increase in drainage, odor, pain to the area, redness, fever, chills, warmth, and delay in wound healing. Pain is an important and under-utilized symptom that signals wound infection. In patients who are nonverbal or with cognitive impairments, facial expressions or flinching with palpation or dressing change can indicate increase in pain to the area. Facial and body expressions are extremely important pain indicators for clinicians during all wound care procedures. If the patient does not or cannot verbally tell us, their body language will.

There are several ways in which surgical wounds can be closed; either by primary intention, with sutures or staples, or left open to heal by secondary intention. Primary intention allow the wound edges to heal by alignment and held together in their original position, mostly by surgical incisions. This technique allows rapid healing with less scarring (Smith & Pravikoff, 2016). Secondary intention leaves the wound open and the edges apart. This occurs commonly in wounds that have infection and require additional treatment to heal. Secondary intention usually results in more scarring because it requires formation of larger amounts of new tissue. In any wound, the strength of scar tissue is never more than 80% of the tensile strength of the original tissue (Bryan & Nix 2015). Tertiary intention can be used when the wound is left open to allow further treatment of the wound surface. The wound is closed after the initial healing has taken place and the risk of infection has decreased (Smith & Pravikoff, 2016).

Dressing instructions will be given by the surgeon. Always ensure that the instructions include providing a moist wound environment and observe the patient and caregiver performing wound care correctly. Discuss adding protein to the diet and always review signs and symptoms of infection as well as the importance of hand hygiene.