1. Chapter 13 Surgical Wound Care
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Wound Classification Wounds Classified According to Cause
Incision or puncture
Severity of injury
Amount of contamination
Clean, clean-contaminated, contaminated, and dirty or infected
Skin integrity
Define the term “incision.”
How does the CDC classify wounds?

3. Wound Healing Phases of Wound Healing Hemostasis Inflammatory phase
Maturation phase
Reconstruction phase
Primary intention
Phases of Wound Healing
Hemostasis
Termination of bleeding
Begins as soon as the injury occurs
Inflammatory phase
An initial increase in blood elements and water flow out of the blood vessel into the vascular space
Causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction
Maturation phase
Fibroblasts begin to exit the wound.
The wound continues to gain strength, although healed wounds rarely return to the strength the tissue had before surgery.
Keloids may form during this phase. What is a “keloid”?
Reconstruction phase
Collagen formation occursa glue-like protein substance that adds tensile strength to the wound and tissue.
Appearance changes to an irregular, raised, purplish, immature scar.
Wound dehiscence most frequently occurs during this phase.
Primary intention
Wound is made surgically with little tissue loss.
Skin edges are close together.
Minimal scarring results.
It begins during the inflammatory phase of healing
Describe the pathophysiology of bleeding termination.
How does the inflammatory phase initiate the healing process of a wound?

4. Wound Healing Process of Wound Healing Secondary intention
Tertiary Intention
Secondary intention
Healing occurs when skin edges are not close together or when pus has formed.
If wound has purulent exudates, the surgeon provides a means for its release via drainage system or by packing the wound.
The necrotized tissue decomposes and escapes.
The cavity begins to fill with granulation tissue.
The amount of granulation tissue required depends on the size of the wound; scarring is greater in a larger wound.
Tertiary Intention
Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together
Occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, is opened, allowed to granulate, and then sutured
What is the difference between purulent drainage and exudates?
What is granulation tissue?

5. Wound Healing Factors That Affect Healing Nutritional needs Fluids
Rest and activity
Factors that impair Wound healing (table 13-1, pg. 313)
Age
Malnutrition
Obesity
Impaired oxygenation
Smoking
Drugs
Diabetes Mellitus
Radiation
Wound Stress
Nutritional needs
If the patient cannot tolerate food or fluids, total parenteral nutrition or nasogastric feedings can be provided.
Because patients may not be able to tolerate large meals or solid foods, dietary services can provide small frequent feedings.
Fluids
Offer hourly; encourage 2000 to 2400 mL in 24 hours.
Monitor I&O’s until hydration is stable ( usually within 24 to 72 hours post-op)
Rest and activity
The nurse assists the patient to achieve a balance between time to rest to facilitate healing and activity to decrease venous stasis.
When the patient is confined to bed, moving one body section at a time should be encouraged.

6. Surgical Wound
What is the basis for selection of wound sites? Pg. (341)
Nursing Interventions in care of surgical wounds
Inspect site- drainage, bleeding, drains
Assess drainage in drains (amount, color, odor)
Documentation
As the exudate subsides, it becomes serous.
Selection of wound site is based on
Tissue or organ involved
Nature of injury or disease process
Process of inflammation or infection
Strength of the site
If a drainage system is required, the position of the drain may also influence the placement of the incision.
Nursing Interventions
The nurse should inspect dressings every 2 to 4 hours for the first 24 hours. If there is bleeding noted mark the edges to note any changes in bleeding
On the day of surgery, most wounds will have sanguineous or serosanguineous exudates.
As the exudate subsides, it becomes serous
Describe these terms: sanguineous, serosanguineous and serous.
Serous drainage- thin yellow drainage, normal from wound with first hours post surgery, copious amounts should be reported to MD. Serous drainage can weep from skin with edema
Serosanguineous-thin, watery drainage that is composed of both blood and serum, slightly pink, normal within first stages of healing.
Sanguineous-has a larger amount of blood present than in serosanguinous drainage, not typical of healing wound, may indicate poor wound care or too much activity too soon after surgery.
Because pressure to the surgical wound retards bleeding, wounds are usually covered by a gauze dressing.
The nurse should inspect both the dressing or incisional area and the area under the patient; exudate follows the flow of gravity.

7. Surgical Wound Fibrin walls off injury The inflammatory response
Phagocytosis
WBC count.
Fluid from the cells clusters with leukocytes along the vessel walls so that fibrin walls off the injury and begins to build a new cell.
The inflammatory response depends on the level of injury inflicted, size of the area involved, and physical condition of the patient
In the inflammatory response blood elements (antibodies, electrolytes and plasma proteins) and water flow out of the vessel into the vascualr phase
Cardinal signs of inflammation :erythema, heat, edema pain and tissue dysfunction
Phagocytosis occurs when exudate from the injured cell is surrounded, engulfed, and digested by leukocytes. Will decrease if no infection
Within 24 to 48 hours wound begins to fill in as new cells are formed
An infectious process would be evidenced by an elevated WBC count.
Reconstruction phase- collagen forms (pg 311)
Why is phagocytosis an important process in wound healing?
Decrease organisms within the wound and promotes wound healing
What is the pathophysiology rationale regarding an elevated WBC and evidence of infection?

8. Care of the Incision
Surgical wounds, because they are aseptically created, generally heal well and quickly.
Incision Coverings
Gauze
Permits air to reach the wound
Semi occlusive
Permits oxygen but not air impurities to pass
Occlusive
Permits neither air nor oxygen to pass
When is a surgical dressing typically removed?

9. Care of the Incision Removing Dressings Dry Dressings
Transparent Dressings
Wet-to-Dry Dressing
Irrigations
Applying a transparent dressing.
Care is taken to avoid accidental removal or displacement of underlying drains.
An analgesic may need to be given at least 30 minutes before exposing a wound.
Sutured, clean wounds may not be dressed after surgery, or dressing may be removed within 24 hours postoperatively to allow air circulation.
Sterile technique is followed whenever the wound or dressing is handled.
A gown, mask, and protective goggles are worn if soiling or splashing of wound exudate is expected.
Dry Dressings
May be chosen for management of a wound with little exudate/drainage
Protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing
Most commonly used for abrasions and nondraining postoperative incisions
Transparent Dressings
Self-adhesive transparent film is a synthetic permeable membrane that acts as a temporary secondary skin.
Advantages
Adheres to undamaged skin to contain exudates and minimize wound contamination
Serves as a barrier to external fluids and bacteria yet still allows the wound to breathe
Promotes a moist environment that speeds epithelial cell growth
Permits visualization of the wound
Wet-to-Dry Dressing
Primary purpose is to mechanically debride a wound.
The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris.
As the dressing dries, it adheres to the wound and debrides it when the dressing is removed.
Commonly used wetting agents are normal saline and lactated Ringer’s solution, acetic acid, sodium hypochlorite solution, povidone-iodine, and antibiotic solutions
Irrigations
Solutions used for irrigations include warm water, saline, or mild detergents.
Principles of basic wound irrigation
Cleanse in a direction from the least contaminated area to the most contaminated area.
When irrigating, all of the solution flows from the least contaminated area to the most contaminated area.
Why would a surgical dressing be removed within 24 hours and open to air?
Why is sterile technique required when handling or changing a dressing?
For what type of wounds would a wet-to-dry dressing be an appropriate procedure?
For what type of wounds would the following solutions be appropriate to use?
acetic acid
Dakin’s
Why would the nurse cleanse a wound from the area of least contamination to the area with the most contamination?

10. Changing a sterile dry dressing.
Dressing Types
Skill 13-1: Steps 9 & 11
Skill 13-1: Step 14
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Changing a sterile dry dressing.

11. Applying a transparent dressing.
Skill 13-3: Steps 11a & 11b
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Applying a transparent dressing.

12. Performing sterile irrigation.
Skill 13-4: Steps 10 & 13
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Performing sterile irrigation.

13. Complications of Wound Healing
Impaired wound healing requires accurate observation and ongoing interventions.
Wound bleeding
Dehiscence
Evisceration
Wound Infection
Impaired wound healing requires accurate observation and ongoing interventions.
Situation can be life-threatening.
Recognizing the seriousness of signs and symptoms is vital throughout the patient’s recovery phase.
Wound bleeding
Bleeding may indicate a slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue.
If internal hemorrhage occurs, the dressing may be dry while the abdominal cavity collects blood.
Dehiscence
Wound layers separate.
Patient may say that something has given way.
It may result after periods of sneezing, coughing, or vomiting.
It may be preceded by serosanguineous drainage.
Patient should remain in bed and receive nothing by mouth, be told not to cough, and be reassured.
The nurse should place a warm, moist sterile dressing over the area until the physician evaluates the site.
Evisceration
Abdominal organs protrude through an opened incision.
Patient is to remain in bed, and the wound and contents should be covered with warm, sterile saline dressings.
The surgeon is notified immediately.
This is a medical emergency, and the wound requires surgical repair.
Wound Infection
Surgical wound becomes contaminated.
CDC labels a wound “infected” when it contains purulent (pus) drainage.
A patient with an infected wound displays a fever, tenderness, and pain at the wound; edema; and an elevated WBC count.
Purulent drainage has an odor and is brown, yellow, or green, depending on the pathogen.
What signs and symptoms would indicate a serious change in the patient’s condition?
What should the nurse monitor to assess for internal bleeding?

14. Surgical Wound
The surgeon’s goal is to enter the cavity involved, repair the injured or diseased area, and minimize trauma as quickly as possible.
Many options are available to the surgeon for closing the surgical incision.
Sutures, staples, Steri-Strips, butterfly strips, and transparent sprays and films
Binder or bandage used to support the incision of secure dressings without the use of adhesive materials

15. Wound closure with staples.
Figure 13-5
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Wound closure with staples.

16. Steri-Strips placed over incision for closure.
Figure 13-6
(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: Essentials for practice. [5th ed.]. St. Louis: Mosby.)
Steri-Strips placed over incision for closure.

17. Staple and Suture Removal
Physicians orders
Stage of healing
Sutures- threads of wire or other materials
Staples-stainless steel wire
Physician’s written order is always obtained before implementing either skill.
The time of removal is based on the stage of healing and extent of surgery.
Sutures and staples are generally removed within 7 to 10 days after surgery, or sooner if healing is adequate.
The physician determines and orders removal of sutures or staples one at a time or removal of every other suture or staple and replaced with a Steri-Strip as the first phase, with the remainder removed in the second phase.
Sutures
Sutures are threads of wire or other materials (silk, steel, cotton, linen, nylon, and Dacron) used to sew together body tissues.
Sutures are placed within tissue layers in deep wounds and superficially as the final means of wound closure.
Deeper sutures are usually made of absorbable material that disappears in several days.
Types include interrupted or separate sutures, continuous sutures, blanket sutures, and retention sutures covered with rubber tubing for strength.
Staples
Staples are made of stainless steel wire, are quick to use, and provide ample strength.
They are popular for skin closure of abdominal incisions and orthopedic surgery when the appearance of the incision is not critical.
Leaving in a suture too long makes removal more difficult and increases the risk of infection.
Removal of staples requires a sterile staple extractor and maintenance of aseptic technique.
Why is it difficult to remove staples that have been in place longer than 10 days? The skin surrounding the staples will begin to adhere and grow around the staple, which causes difficulty and pain upon removal.

18. Skill 13-5: Step 9 Removing staples.
(From Perry, A.G., Potter, P.A. (1998). Clinical nursing skills and interventions. (4th ed.). St. Louis: Mosby.)
Removing staples.

19. Exudate/Drainage Exudate Drainage Serous Assess Sanquinous
Serosanginous
Assess
Type
Amount
Color
Consistency
Odor
Exudate
Fluid, cells, or other substances that have slowly exuded from cells or blood vessels through small pores or breaks in the cell membrane
Drainage
Removal of fluids from a body cavity, wound, or other source of discharge through one or more methods
Serous
Clear, watery fluid that has been separated from its solid elements
Sanguineous
Fluid that contains blood
Serosanguineous
Thin and red; composed both of serum and blood
If the tissue is infected, exudate/drainage may be brown-green purulent.
Exudate/drainage from organs has its own particular color. (Bile from the liver and gallbladder is green-brown
The type and amount produced depend on the tissue and organs involved.
More than 300 mL in the first 24 hours should be treated as abnormal.
When patients first ambulate, a slight increase may occur.
Assess
Color, amount, consistency, and odor
It may be contained either in a drainage system or on a dressing.
Group discussion
Why would the nurse anticipate an increased exudate or drainage when the patient first ambulates?
Why is it important to note the following characteristics?
color
amount
consistency
odor
When should a wound culture be obtained?
Why is it important to mark and date drainage noted for a dressing?

20. Exudate/Drainage Drainage Systems Closed drainage Open drainage
Suction drainage
Drainage Systems
They are used in procedures in which organs were removed or repaired.
A mechanism is needed to assist gravity in removing exudates from the cavity.
To facilitate drainage, an incision or a stab wound is made close to the incision and drains exudate away from the incision.
Closed drainage
System of tubing and other apparatus attached to the body to remove fluid in airtight circuit that prevents environmental contaminants from entering the wound or cavity
Open drainage
Drainage that passes through an open-ended tube into a receptacle or out onto the dressing
Suction drainage
Use of a pump or other mechanical device to help extract a fluid
Why is it important to drain fluid from a surgical site?

21. Exudate/Drainage Drainage Systems Requires close monitoring
Care of the patient with a T-tube drainage system
Wound vacuum
Requires close monitoring
Note the color, consistency, and amount of drainage.
Note patency of tube; it should not be kinked or occluded. If blood clots or exudate have slowed drainage, record and report.
Care of the patient with a T-tube drainage system
After surgical removal of the gallbladder, the bile duct is often inflamed and edematous.
A drainage tube is frequently inserted into the duct to maintain a free flow of bile.
The long end of the T-tube exits through the abdominal incision or a separate surgical wound.
The tube drains via gravity into a closed drainage system.
The collection bag is emptied and measured every shift.
Wound Vacuum
Accelerates wound healing- promotes formation of grannulation tissue, collagenn, fibroblast and inflammatory cells
Nursing Interventions:
Measure wound –baseline prior to initiating therapy
Ensure vacuum tight seal
Assess, record and empty drainage
Document information on wound
Group activity
Why should the nurse closely monitor the drainage system?
Why is a T-tube necessary following surgical removal of the gallbladder? Bile duct is inflammed
How does wound vac work? Pg 330

22. Maintaining Hemovac/Davol suction and T-tube drainage.
Skill 13-6: Step 6
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Maintaining Hemovac/Davol suction and T-tube drainage.

23. (Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Figure 13-10
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Wound VAC system using negative pressure to remove fluid from area surrounding the wound.

24. Skill 13-7: Step 2 Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Wound Vacuum-Assisted Closure.

25. Skill 13-7: Step 12a, A Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Wound Vacuum-Assisted Closure.

26. Skill 13-7: Step 12a, B Wound Vacuum-Assisted Closure.
(Courtesy of Kinetic Concepts, Inc. [KCI], San Antonio, TX.)
Wound Vacuum-Assisted Closure.

27. Bandages and Binders Bandage Binders
Correctly applied bandages and binders do not cause injury to underlying and nearby body parts or create discomfort for the patient.
Bandage
A strip or roll of cloth or other material that may be wrapped around a part of the body in a variety of ways for multiple purposes.
Bandages are available in rolls of various widths and materials, including gauze, elasticized knit, elastic webbing, flannel, and muslin.
Binders
A binder is a bandage that is made of large pieces of material to fit a specific body part, such as an abdominal binder or a breast binder.
Before a bandage or binder is applied
Inspect the skin for abrasions, edema, discoloration, or exposed wound edges.
Cover exposed wounds or open abrasions with sterile dressings.
Assess the condition of underlying dressings and change them if soiled.
Assess the skin and underlying body parts and parts that will be distal to the bandage for signs of circulatory impairment.
When would a bandage dressing be appropriate?
When would the use of a binder be appropriate?
Why is it important to assess the skin when applying a bandage or binder?
Why is it important to utilize sterile technique when applying a bandage or binder?
Why is it important to assess the site and the peripheral area for signs of circulation?

28. Applying a binder, arm sling, and T-binder.
Skill 13-9: Step 5c
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Applying a binder, arm sling, and T-binder.

29. Applying a binder, arm sling, and T-binder.
Skill 13-9: Step 5d
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Applying a binder, arm sling, and T-binder.

30. Bandages and Binders After a bandage is applied, the nurse should
Assess, document, and immediately report changes in circulation, skin integrity, comfort level, and body function such as ventilation or movement.
Loosen or readjust as necessary.
Have an order to remove or loosen a dressing applied by a physician.
Explain to the patient that any bandage or binder feels relatively firm or tight.
Assess to be sure it is properly applied and is providing therapeutic benefit; soiled bandages should be replaced.
Why is it important to assess?
skin integrity
circulation
comfort
body function
When should the nurse loosen or change a bandage or binder?
What should the nurse document after applying a bandage or binder?

31. Nursing Process Nursing Diagnoses Skin integrity, impaired
Nutrition: more than body requirements, imbalanced
Nutrition: less than body requirements, imbalanced
Tissue perfusion, ineffective