Infection prevention in surgical patients

with abdominal wounds Doris Appiagyei Agyare & Manisha Udash

2018 Laurea

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Laurea University of Applied Sciences

Infection prevention in surgical patients

with abdominal wounds

Doris Appiagyei Agyare

Manisha Udash Degree Programme in Nursing Bachelor’s Thesis November 2018

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Laurea University of Applied Sciences Abstract

Degree Programme in Nursing

Bachelor’s Thesis

Doris Appiagyei Agyare & Manisha Udash

Infection prevention in surgical patients with abdominal wounds

Year 2018 Pages 48

Surgical site infections (SSIs) are one of the major common adverse events that occur with

hospitalized surgical patients. The incidence of SSI after a surgical procedure is highly varia-

ble depending on the type of surgery being done and the underlying risk factors of the pa-

tient. Surgical site infection can cause longer stays in the hospital and additional surgery

sometimes causing longer queues for incoming patients, financial loss to families and to the

country as a whole.

Infection control measures should be applied from the beginning of admission of the patient

to the hospital, preoperative phase, intraoperative and postoperative phase. Nurses, sur-

geons, ward doctors and cleaning personnel play a major role in prevention of infection as

they deal with patients.

The study method was qualitative and the data was collected by interviewing four registered

nurses in the gastrointestinal surgical ward. Four main categories were formed from the data

by using inductive content analysis which are Observant daily wound care, Considering risks,

Educating patients and Follow-up of the procedures.

The findings reveal that the process nurses follow to prevent infection during postoperative

care is also connected to the preoperative phase. All the answers given really showed that

the nurse’s knowledge about abdominal wound infection is deep due to their experiences.

Basic knowledge of aseptic techniques and its applications are fundamental ways of prevent-

ing surgical site infection from the onset.

Keywords: Abdominal wound, infection prevention, surgical patients, nursing intervention,

surgical site infection (SSIs)

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Table of Contents 1 Introduction .............................................................................................. 5

2 Surgical patients ......................................................................................... 5

2.1 Patients with abdominal surgery ........................................................... 7

2.2 Nursing intervention in abdominal surgery .............................................. 7

3 Abdominal surgery ...................................................................................... 9

3.1 Pre-operative phase ......................................................................... 10

3.2 Intra-operative phase ....................................................................... 11

3.3 Post-operative phase ........................................................................ 11

4 Surgical abdominal wound ........................................................................... 12

5 Surgical infection ...................................................................................... 13

5.1 Infection risk factors ........................................................................ 16

5.2 Infection prevention ........................................................................ 17

5.3 Improving infection prevention ........................................................... 18

6 Research question and purpose of the study ................................................... 19

7 Thesis research method ............................................................................. 20

7.1 Data collection process ..................................................................... 20

7.2 Data collection ................................................................................ 22

7.3 Data analysis .................................................................................. 23

8 Findings .................................................................................................. 26

8.1 Observant daily wound care ............................................................... 27

8.2 Considering risks ............................................................................. 27

8.3 Educating Patients ........................................................................... 28

8.4 Follow-up of the procedures after wound care ....................................... 29

9 Discussions .............................................................................................. 30

9.1 Discussion of the findings .................................................................. 30

9.2 Ethical considerations of the thesis ..................................................... 31

9.3 Trustworthiness of the thesis ............................................................. 32

9.4 Conclusions and recommendations ...................................................... 33

References ................................................................................................... 35

Table ........................................................................................................... 40

Figures ......................................................................................................... 41

Appendices ................................................................................................... 42

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1 Introduction

Surgical site infection has become one of the most leading cause of hospitalized postoperative

patients. It is one the most widely concerned issues that surgical patients have been facing

and it has remained a major source of illness in surgical patients. Infection occurs at the op-

erated part of the body. And it arises after 30 days of the surgery or up to 1 year in patients

receiving implants affecting deep tissue at operation site. The infection can be superficial,

involving the skin or tissues under the skin or organs. The chances of SSI can be as high as 20%

depending on the different types of the procedure taken place during the surgery. According

to Burke (2003, 651–656) surgical site infections (SSIs) are considered to be the second most

common cause of nosocomial infections.

It is important that nurses try to prevent infection in abdominal wound surgery patients and

during the healing process. Informants of this thesis are registered nurses, who have had ex-

periences with post-operative abdominal wound infection patients. The thesis will focus on

nurses’ interventions and guidance with such patients; diagnosis, plan, evaluation and imple-

mentation. The findings might be helpful information for future nurses and patients as well.

According to the Annual epidemiological report for 2014, 18 364 SSIs were reported from a

total of 967 191 surgical procedures and percentage of SSIs per 100 surgical procedures varied

from 0.6% to 9.5% depending on the type of procedure. SSI can require longer hospital stays

and additional surgery causing longer queue for incoming patients, financial loss to families

and the country as a whole. Surgical site infections, is one of the side effects that occurs

after a patient undergoes for surgery (Seltzer et al., 2002).

Basic knowledge of aseptic techniques and its applications are the fundamental ways of pre-

venting surgical site infection from the onset. The purpose of the thesis is to describe what

nurses do to prevent infections in surgical patients with abdominal wounds. Primary concern

in healthcare today is the prevention of infection.

2 Surgical patients

A surgical patient can be defined as an acute sick person who might have a life-threatening

situation in most cases or vice versa. A surgery can be performed either on the level of urgen-

cy, risk or a purpose. A level of urgency is the situation whereby a quick surgery is done to

control or reverse life-threatening incident or to preserve function of life. Any delay in urgen-

cy surgery could be catastrophic and might be also be irreversible. It normally requires obser-

vation within 24-74 hours. Example of urgency cases can be surgery to repair gunshot wound,

control of haemorrhage. Urgent appendectomy is also an example. None withstanding, a sur-

gery can also be conducted at both patient and surgeon convenient time mostly depending on

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the patient’s medical health condition a day before or some minutes before the surgery is

done. If it is not seen as a life-threatening condition, it is rather performed to enhance pa-

tient’s well-being or quality of life.

All the same, not performing the surgery would definitely not be any alarming repercussions

rather than performing the surgery and putting the life of the patient at risk. For example, a

hip-replacement surgery can be postponed, removal of uterus due to severe menstrual cramps

etc (Schuster at el., 2009). Furthermore, a surgery can be done on purpose not because the

patient has any medical problems but it is done due to patient’s preference in order to im-

prove his or her appearance. Examples can be repair of scars from burns, circumcision, and

plastic surgery to alter a perfect body shape. After preliminary assessments, patients are

given anaesthetic medications for sedation before being transported to the OR. ASA monitors

are used throughout the surgery with cardiorespiratory end-points documented at 5-min in-

tervals (Arain et al., 2004)

A surgical patient can be put into two categories: Outpatient or Inpatient.

An outpatient is a patient, who is not hospitalized overnight but goes to hospital or any health

care centre for treatment whether the situation is an emergency or vice versa and returns

home after been treated that same very day. It can also be check-ups. An out-patient is not

kept at the hospital for more than 24 hours. The patient’s information needs to recorded

even though there is not going to be any overnight stay. For example, a patient going for a

tooth extraction surgery, an arthroscopic knee washout, an opened wound closure etc. can be

classified as outpatients.

After discharge, a telephone follow-up (Quemby & Stocker, 2013). Nurses should have good

assessment skills and knowledge in caring for outpatients. Especially, obtaining good commu-

nication skills with patients, anaesthesiologists and surgeons. Nurses should be able to have

adapting competence as well since day surgery unit always have fast turnover of patients

(Voda, 2011).

An inpatient on the other hand is admitted at the hospital and stays overnight for a period of

days. Mostly inpatients require frequent monitoring during and after treatment. Since they

tend to have more demanding cases which might deteriorate at any given time so a close

medical observation should be kept on them to avoid further complications. They are dis-

charged after their conditions are stabilized and can manage on their own without any

healthcare worker being around them all the time. There are exceptional cases whereby pa-

tients stay overnight during admission but will not have an inpatient status. (Walker, 2002)

More importantly, the diagnosis, evaluation and the surgical care of the patient are mainly

the responsibilities of the surgeons. They make sure the patient undergoes preoperative as-

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sessment. The assessment normally includes patient's chart and an independent diagnosis by

the surgeon in charge of the surgery (Plauntz, 2007). The operating surgeon discusses with the

patient or significant others concerning the type of the surgery, diagnosis and risks involved.

Re-evaluating the patient quickly prior to the operation is also the duty of the patient. Gain-

ing patients’ confidence, assuring help available and will be provided.

The evaluation and management of the surgical patient pre, intra and post phase is part of

the primary responsibility of the surgeon (Walker,2002). After the surgery is done, postopera-

tive notes should have the findings encountered during the surgery (Mohabir & Gurney, 2015).

Patient positioning plays a major role during the surgical operation even though some sur-

geons might have their own preferences. Good positioning also helps in prevention of pressure

sores O'Connell (2006).

2.1 Patients with abdominal surgery

Patients with abdominal surgery are considered as patients with abdomen problems whereby

an operative procedure, in which the abdominal cavity is opened, and surgeons repair dam-

aged, redundant or malignant tissue causing discomfort for the patient. The most common

ones are; inguinal hernia repair, exploratory laparotomy, appendectomy and laparoscopy.

Patients who have undergone abdominal surgery have incisions that need to be checked on a

daily basis to foresee an oncoming surgical site infection (Strik et al., 2016).

They are at a higher risk of wound dehiscence (direct wound inspection) especially when the

anterior wall is not closable, the risk of anastomotic leak and enter atmospheric fistula be-

come high and abdominal compartment syndrome (bladder pressure monitoring). Patients

with abdominal surgery can also be classified as ICU patients since they need constant moni-

toring.

Possible complications patients with abdominal can encounter are; excessive bleeding, wound

infection, incisional hernia, recurrent gastric ulcer, chronic diarrhea, malnutrition; pain,

swelling, redness, drainage or bleeding in the surgical area; headache, muscle aches, dizzi-

ness or fever; increased abdominal pain or swelling, constipation, nausea or vomiting; rectal

bleeding or black stools Piper & Kaplan (2016).

2.2 Nursing intervention in abdominal surgery

The role of the nurse is to intervene for patients by promoting and maintaining health, pre-

vention of illness /infection, aim to support, treat patient as a fellow human being, listening

and empathizing with patients and last but not the least, alleviating suffering (Schubert et

al., 2008). A nurse enlightens the patient on the type surgery he/she is going for and also

prepares the patient mentally, emotionally and physically to reduce stress and anxiety. Nurs-

es should be able to identify surgical site infection mostly caused by previous cases. If a cath-

8

eter or a cannula is inserted during the surgery, it is the nurses’ responsibility to remove it

when it is no longer needed since it can cause infection. Cannula should be changed into a

different position if the patient will be needing more fluids.

Constant observations should be carried out on patients when they are transferred from the

theatre to the recovery room. Nurses keep close eyes by constantly monitoring patients’

blood pressure, temperature, pulse, breathing and oxygen levels. During the course of this,

the wound dressing is also checked to see if there is any excessive bleeding. The oxygen

mask is not removed until the effects of the anesthetic are worn off. (Burke 2003; Sessler

2006). Patients are transferred back to the ward after some minutes or hours depending on

how consciousness level will be. All patients are assessed for severity of pain using either a

verbal rating scale or a visual analog scale.

Pain control is also essential since some patients may end having the Patient Controlled Anal-

gesia pump (PCA). This contains a strong painkiller and it is controlled by the patient. Once

the patient presses the hand-held button, the set amount of painkiller from the syringe goes

direct into the vein in your arm or hand. The whole procedure is regulated in a way that, the

patient cannot get over dose even if the patient wants to and it also controlled by the nurses

frequently. There are other choices like tablets, or liquid to swallow to control any pain the

patients may have. Alleviating patients’ pain is a paramount importance during the nursing

interventions (Walker, 2003). Deep Vein Thrombosis (DVT) is likely to occur after surgery due

to blood becoming stagnant in veins because of patients’ capability of moving around has

become limited in the ward. Because of this, surgeons prescribe DVT drugs to prevent blood

clot (Saltissi et al., 1999).

Also, educating patients and their significant others is also another way of minimizing surgical

site infections. The only procedure for nurses is to try their possible best to nurse them for

quicker recovery before discharge since some patients will not follow the verbal and written

information given to them to follow once discharged; patients going home should have re-

sponsible escort (Quemby & Stocker, 2013). Furthermore, some patients do not understand

the importance of mobility and how to take care of their wounds after surgery so nurses go

extra mile to educate patients even more and at the same motivate them on how to take

good care of their health. Well, there are cases whereby patients upon understanding all the

in-formation said and written, they still think it is a nurse responsibility to take care of them

(Kalisch, 2006).

Furthermore, hygiene is one of the key factors that helps in prevention of infection. The

nurses help the patients to have a wash or shower if the patient is not mobile enough to do it.

The wound should be kept dry with a clean dressing at all the time (Wysocki, 1989). Before

the patient is being discharged, the stiches are removed by nurses. If there may be a need if

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nutritional support, the nurse calls in the nutritionist for the patient. Direct communication

with the significant others is sometimes established to have some realistic goals of care. Be-

fore the patient leaves the hospital, nurses make sure the patient fully understands the sur-

gery that was done and the simple instructions to follow at home to avoid complication or

infections. For example, avoiding lifting heavy objects, how to take prescribed drugs if there

is any.

3 Abdominal surgery

Abdominal part of the body widely includes stomach, small intestine, large intestine, liver,

gallbladder, pancreas, and spleen and abdominal surgery usually covers surgical procedures

that includes abdomen. Different part of abdominal surgery depends upon the patient’s situa-

tion for example, infection, obstruction, tumors, inflammatory bowel disease or traumatic

injury or natural disease. Most of the common abdominal surgeries are as inguinal hernia sur-

gery, abdominal exploration surgery, appendectomy or surgery for inflammatory bowel dis-

ease, which may consist of removing all or part of the small or large intestine (Florida Hospi-

tal, n.d.)

Appendectomy is the most common surgery which involves removing of appendix. Inflamma-

tion of the appendix is known as appendicitis in this situation, appendectomy procedure is

performed. Appendectomy can also be sometimes performed as another type of abdominal

procedure. In a situation when appendectomy is performed where appendix is already rup-

tured, a longer hospital stay is needed whereas, if the appendix is not ruptured, it is quickly

recovered.

‘‘Laparotomy is performed to explore abdominal called as exploratory laparotomy when clini-

cal diagnostic methods are unable to find the cause of various abdominal symptoms. It is per-

formed in patients with acute abdominal pain that may be due to some abdominal trauma.

Additional surgery might be performed after finding the cause from this procedure (Vikram

Kate, 2017).

Laparoscopy is the most common less invasive method used or preferred for diagnosing differ-

ent intra-abdominal diseases. In this procedure, several small holes are made surgically in the

wall of the abdominal, where tubes are inserted into the holes. A small camera is fixed in one

of these tubes to look through the abdominal cavity without making big incision. This method

is often used when performing a cholecystectomy, or gallbladder removal. Decreased post-

operative pain, reduced morbidity and short hospital stay are most common advantage of

using this method.

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3.1 Pre-operative phase

This is the phase when a patient has decided to go for the surgery with all consent forms

signed. It begins from the ward to anesthesia room and to the operating room. During this

phase, all kind of assessment are done according to the age of the patient as young and older

aged people are at more risk for having complications during the surgery. Some of the as-

sessment done during this phase are as patients’ nutritional status, fluid and electrolyte sta-

tus to prevent hypovolemia during surgery.

Similarly, presence of infection, other health problems related to cardio, respiratory, renal,

neurologic, hematologic, etc. The use of medication to prevent the life-threatening situation

during and after the surgery and lastly lifestyles like habit of smoking to be prepared before-

hand. Sometimes this phase can be extremely short in case of acute trauma and can be long

preparation in a case a patient needs to fast or lose weight (Jennifer Whitlock, updated

2018).

Pre-operative phase also helps a patient to overcome the anxiety and stress for oncoming

surgery which is called as Preoperative anxiety. Nonmedical interventions such as hypnosis

and guided imagery has been shown to reduce pain, anxiety, and length of stay in patients

undergoing diverse surgical procedures (Antall 2004; Halpin 2002; Lambert 1996). Example,

deep breathing, turning, splinting, and purse- lip breathing exercises and this can be very

useful for preventing complication like pneumonia and respiratory problems. This phase also

includes process of obtaining consent from the patient after informing and explaining the

details of the surgery to be performed and the prescribed medications like tranquilizers, sed-

atives, analgesics, and anticholinergics are also prepared (Clinical guidelines, 2008).

Surgical site infection can also be prevented starting from this phase. According to the Clini-

cal guidelines by National Institute for Health and care Excellence, 2008, these are the pro-

cedures needs to be followed during this phase: Patients are advised about pre-operative

shower or bath using soap either the day before or on the day of the surgery. Likewise, re-

moving hair regularly can be a risk for getting SSI (Surgical site infection) and if the hair

needs to be removed for the surgery, it can be done by using electric clippers but not with

razer as it increases the chance for infection. Patient’s theatre wear needs to be appropriate

for easy access according to the patient’s comfort and dignity, and staff’s theatre wear needs

to be non-sterile where the operation is undertaken. Removing any kind of hand jewellery or

nail polish, avoiding the use of mechanical bowel preparation regularly are also very im-

portant for prevention infection.

Lastly, use of Antibiotic prophylaxis is done according the type of surgery performed, howev-

er, informing patients before the operation, whenever possible, if they will need antibiotic

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prophylaxis, and afterwards if they can be given antibiotics during their operation is always

done in the pre-operative phase.

3.2 Intra-operative phase

This is the second phase of surgery and where the surgery is performed; it starts when the

patient is transferred to the operating room till the patient is re-transferred to the recovery

room after the operation is done. The surgical team consists of surgeon, assistant surgeon,

anesthesiologist, holding area nurse, circulating nurse and scrub nurse. The verification of the

checklist, prescribed medications, consent form and various preparation including exact posi-

tion of the patients and skin preparation are usually done the surgical team. Surgical sepsis is

also maintained highly in this phase which includes health of the surgical team, surgical attire

and surgical scrub.

The role of the circulating nurse is to monitor the patient’s well-being in collaboration with

surgeon and anesthesiologist, providing solutions, supplies and instruments, and documenting

the progress of the surgery. Likewise, scrub nurse assists the surgeon by handling instruments

and supplies to the surgeon while maintaining surgical sepsis. (Daisy Jane Antipuesto RN MN,

2011).

The first and most important part for preventing SSI in this phase is, hand decontamination,

surgical team need to wash their hand using aqueous antiseptic surgical solution ensuring that

hand are visibly clean (NICE Clinical Guidelines, 2008) Iodophor-impregnated drape is usually

recommended to be used to reduce surgical site infection unless patient has an iodine allergy.

Sterile gowns and gloves are other most essential part for preventing infection. Similarly, skin

preparation must be prepared with an antiseptic and wound irrigation and intracavity lavage

cannot be used.

Lastly, before wound closure the operated part of the skin should be re-disinfected. Topical

cefotaxime should not be used in abdominal surgery to reduce the risk of SSI. At the end of

the operation, the incisions should be covered with appropriate dressing (Clinical guideline,

2008).

3.3 Post-operative phase

The post-operative phase is the final phase which starts from the time of admission of patient

in the recovery room to the follow up evaluation (ward). The care given during this phase

mainly focuses on the patient’s physiological health and post-surgical recovery. The ABCS,

airway, breathing, and circulation, oxygen saturation and ventilation, vital signs and level of

consciousness are firstly assessed. This is the phase where Nursing intervention is followed up

and some of the assessment may include ensuring hydration, monitoring urination or bowel

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movements, assisting with mobility, providing appropriate nutrition, managing pain, prevent-

ing infection, etc. (Jennifer Whitlock, updated 2018).

The greatest complication that occurs during this phase is the wound healing process. There

are cases wound takes longer depending on the type of surgery performed. According to Got-

trup F 2004, oxygen therapy is important in relation to both healing and resistance to infec-

tions. However, the most severe postoperative complication can be the development of pres-

sure ulcers, or bedsores. These ulcers grow at pressure points in patients who are incapable

or unwilling (because of pain) to shift their positions in bed; early signs of their development

can be present within two hours of pressure being applied (Bansal, 2005).

In order to prevent SSI in this phase, all preventing measures should be taken during the first

two phases. Besides this, some of the examples of other measures are as using an aseptic

non-touch technique for wound dressing; sterile saline for wound cleansing up to 48 hours

after surgery; advising patient to safely shower 48hours after surgery and etc. Antibiotic

treatment of surgical site infection is also common when surgical site infection is suspected

and needs of giving antibiotic that covers the likely causative organisms.

4 Surgical abdominal wound

A cut or incision made by scalpel in the skin during surgery and sometimes drain place during

surgery is also known as surgical wound. The size of the wound depends on the type of sur-

gery being performed. Surgical wounds are usually closed by sutures, staples or tapes but

sometimes left open for healing depending on the type of surgery (Wysocki, 1989).

The different types of surgical wound have been classified into four. In Class I, the surgical

wound is clean and shows no sign of infection or inflammation. This type of surgery includes

laparoscopic surgery involving skin, eyes, or vascular surgeries. Class II is a clean contaminat-

ed wound that shows higher risk of infections because of its locations like gastro-intestinal,

respiratory or genitourinary tracts.

Wounds are considered as Class III when outside object comes in contact with the skin causing

higher risk of infection. Class III can also be de-scribed as an open, traumatic wound and some

examples are gunshot, blade or other sharp objects causing contamination to the surgical

wound. Class IV (old traumatic wound containing dead tissue) is considered as dirty contami-

nated wounds that have been exposed to pus or faecal matter.

Wound closure is a major key factor during surgical operation because when a wound is closed

properly, there is a low risk of outside bacteria entering it to cause infection. Wysocki cate-

gorized wound closure into three types; “Primary closure, Secondary closure and delayed

closure”. Primary closure also known as healing by primary intention is the quickest closure

with minimal scars. It is clean has low risk of infection. Often, all the layers are closed and

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patients are not bothered by wound care specialist. Secondary closure which can also be

called secondary intention has deep layers and the healing comes from within. More time is

needed during the secondary wound closure and comes up with more tissue loss. It normally

occurs in trauma and infection cases.

Lastly, delayed closure or healing by tertiary intention can be described as the combination

of primary and secondary whereby a wound specialist attention is required due to infection.

Delayed wound is not closed straight after a surgery has been done but it is left opened for

couple of days for inspection of infection before it is closed. A typical example of delayed

wound closure is dog bite.

According to Guo & DiPietro (2010), wound healing can be very complex with many factors

contributing to the overall healing process. Wound healing occurs as a series of overlapping

and often simultaneous stages and is the process whereby the continuity of the injured tissue

is restored. And in order for a wound to be healed; it has to pass through four phases which

are Hemostasis, Inflammation, Proliferative and Maturation. Hemostasis, is the first phase of

the healing process. During this phase, the first thing to do is to stop the wound from bleed-

ing. In other words, a” first aid” intervention is being practiced. The platelets come into con-

tact with collagen causing activation and aggregation. The thrombin therefore strengthens

the platelet clumps into a stable blood clot.

During the Inflammation phase which can also be called as defensive; it deals on destroying

the bacteria and clearing the debris causing thromboxane and decrease in blood loss. The

white blood cells leave while macrophages arrive to continue to clear the debris. This phase

normally lasts 4 to 6 days and is often associated with edema, reddening of the skin, heat and

pain. The Proliferative on the other hand focuses on filling and covering the wound. The

damaged area of the wound begins to rebuild with the help of the granulation tissues

(Wysocki, 1989).

Furthermore, the angiogenesis rebuilds the blood vessel and with the help of the collagen,

new blood vessels are able to grow. The Proliferative phase often lasts 4 to 24 days. The final

healing process of a wound is the Maturation phase. Here, the collagen reconstructs and tis-

sues mature with tensile strength. This phase begins from the 3rd week and it carries on to 9-

12 months before it heals depending on the type of wound (Tonnesen et al., 2000).

5 Surgical infection

According to Burke (2003, pp. 651–656)” surgical site infections (SSIs) are considered to be

the second most common cause of nosocomial infections. And can also, lead to longer stay in

the hospital causing long queue in admission and increase of health care costs. Statistics

about nosocomial urinary tract infections constituted 42% of the infections while surgical

14

wound infections 24%. Patients undergoing intra-abdominal and extra abdominal surgical op-

eration are bound to develop an SSI (Haley et al, 1985). Upon all the phenomenal precautions

in the use of surgical techniques and prophylactic antibiotics, surgical site infections still re-

main a significant cause of patient mortality and morbidity (Bratzler et al., 2005).

Surgical site infections (SSIs) are mostly acquired during the intraoperative and postoperative

phase. There are cases whereby it can also be acquired during the preoperative phase. It is

mostly common and inevitable in some cases. Since there are situations whereby the pa-

tient’s own body gets infected by contamination of the incision with microorganisms during

the intraoperative phase (endogenous bacteria). This makes patients tend to end up in the

intensive care unit (ITU) and in the high dependency unit (HDU) (Kirkland et al. 1999).

According to Nichols (1998) many factors such as length and type of surgery, the surgical

team, medical history of the patient, surgical instruments, or etc. contribute to perioperative

infection. Generally, surgical wound infection is caused by bacteria like staphylococcus and

pseudomonas and streptococcus. SSIs can also be caused in so many other ways by surgical

team, disregarded written surgical principles, use of unsterile surgical instruments, germs in

the air, operating environment (exogenous bacteria). Morbidity and mortality in postsurgical

care are the main results by surgical site infection (Young & Khada, 2014).

Emergency patients are prone to have SSIs due to fast preparation or shortage of surgical staff

because it is sometimes after the normal duty working hours. This can lead to insufficient

preparations such as a thorough sufficient skin preparation that is, washing the part of the

skin that needs to be operated on with chlorhexidine gluconate cleanser or any skin disinfect-

ant within the operating room. Generally, during those rush hours the main focus is being

based on how to save the patients’ life.

Longer explosion of the tissues during the intra phase can cause SSIs especially if the patient

is host risk factor. The ASA score helps in grading the patients’ going for surgery capability

status if they are at high risk. Chances of hypothermia occurring in the intra phase is very

high. The goal of antimicrobial prophylaxis is to prevent infection which is likely to occur

during the surgical operation procedures but methicillin-resistant staphylococcus aureus

(MRSA) is another bacterium which resists commonly used antibiotics causing slow wound

healing. Since it mostly causes mild infection on the skin, constant antibiotics should be ad-

ministered on the surgical site to prevent infection (Mangram et al., 1999).

Forasmuch as SSIs is bound to happen, it takes days before the manifestation on the skin but

it definitely shows signs. Any operated part of the skin which has been infected will show the

following signs and symptoms: swelling redness, fluctuation, turbid aspirate, pain, slow heal-

ing and hyperthermia (Wysocki, 1989).

15

Figure 1: Cross-section of abdominal wall depicting CDC classifications of surgical site infec-

tion. (Mangram et al 1999, p5)

16

According Owen & Stoessel (2008), surgical site infections normally take place within 30 days

after the surgery and has been categorized into 3, superficial, deep and organ incisional.

SUPERFICIAL INCISIONAL DEEP INCISIONAL ORGAN INCISIONAL

• Involves only the

skin, subcutaneous

tissue

• Creates pus

• Intentional reopen-

ing unless culture of

incision is negative

• Purulent drainage

• Isolation of organism

from tissue in inci-

sion

• Involves deep soft

tissue

• Occurs when there is

purulent drainage

• Radiologic exam

• Intentional reopen-

ing on its own or

from surgeons

• Involves any area of

the body such as

body organ or space

between organs

• Occurs 30 days after

the postoperative

phase or within 1

year if an implant is

present.

• Purulent drainage

• Organism isolation

from organs

Table 1: Types of surgical site infection

5.1 Infection risk factors

Risk of infection can be described as "the state in which an individual is at risk to be invaded

by an opportunistic or pathogenic agent (virus, fungus, bacteria, protozoa, or other parasite)

from endogenous or exogenous sources". The risk factors that may increase infection in the

hospital include; long stay in the hospital after surgical operation, the type and length of the

surgery performed on the surgical patient may have an impact, overuse of antibiotics, inci-

sions, surgical equipment and high-risk areas in the hospital such as ICU and HDU (Kirkland et

al.,1999).

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The identification of risk factors contributes to the creation of SSI prevention strategies, thus

allowing health professionals to take actions that reduce complications resulting from infec-

tions and minimize SSI rates. There are four main factors which mostly influence the infection

rates in surgical wounds. They include, Patient variables, Preoperative preparation, In-

traoperative procedure and Postoperative care.

A good health condition plays a pivotal role during the three phases of surgery and helps the

patient to recover quickly with or without any infection contamination. But not all patients

are lucky to have good medical condition and as a result of that, they are already labelled as

risk factor and are also vulnerable to infections due to their endogenous. Their health status

can easily change instantly during preoperatively, intraoperatively and postoperatively phas-

es. Examples of such patients are; Peripheral vascular disease, Overweight, Diabetes mellitus,

Smoking, Cancer, Elderly patients, Medical problems, Chronic skin disease, Malnutrition, Im-

munosuppression, Radiation, Anaemia, Carrier state (e.g. chronic staphylococcus carriage)

(Pomposelli et al.1998; Johnson et al. 2006).

5.2 Infection prevention

Prevention of SSIs is very complex endeavor requiring all the multidisciplinary team with the

involvement of the patient as well sustained (Wysocki, 1989). Surgical site infection (SSI) dur-

ing the postoperative phase is very especially when the surgery performed was about laparot-

omy. Appropriate care during and after surgery helps prevent infections and contributes to

fast wound healing. Proper preoperative skin antisepsis reduces postoperative infection since

the skin can be the main source of bacterial that causes SSI. Before the perioperative phase,

previous infection should be treated. But diabetic patients should be put under control and

regular follow ups to have a good stable blood level.

Administration of prophylaxis antibiotics during preoperative phase of surgery before the in-

traoperative phase begins. The antimicrobial prophylaxis helps in preventing postoperative

infections. Clipping instead of shaving, stable normothermia, and oxygen supplementation

preoperatively, good closure of the incision are vital factors that contribute in prevention of

infection. Prophylaxis antibiotics can be used in any situation where there is a risk of contam-

ination or there is an expectation of an infection. Clean environment starting from the ward,

the operating room and to the recovery room plays a major role (Owen & Stoessel, 2008).

Strict aseptic techniques such as the surgeons and scrub nurses wearing clean surgical gowns

and headgear, washing their hands and forearms with sponges and brushes with the applica-

tion of antimicrobial soaps, iodine or chlorhexidine McHugh et al., Anesthetic technicians

must go sterile when administering epidural and spinal anesthesia, avoidance of unnecessary

excessive cautery during incision, changing of gloves (Chang et al 2010). When there is a hole

or too much stain of blood all contribute major factor in prevention of infections with the

18

limitation of activity that does not concern the operation and too much talking during the

intraoperative phase. Furthermore, good blood supply and fluids using a warmer if the surgery

will last more than an hour to avoid hypothermia and hyperglycemia (Sessler, 2006).

Isolation of infected patients from uninfected patients to a room of their own is very para-

mount since infection is known to be transferable from one patient to another. If possible,

infected patients should have their own nurses like it is done in the recovery room after sur-

gery. Patients who are infected can be put in the same room with patients who are host risk

of SSIs. The isolation helps healthy recover faster and enables early discharge and minimizes

hospital costs and long patients’ queues in the hospital.

Postsurgical wound care after abdominal surgery, after wound has been closed patients will

automatically go a random dressing change will be take place every two days. But the must

be protected from any possible contamination by sterile dressings for minimum of 24 hours

before it is changed. During this phase, proper aseptic techniques must be followed in order

not to contaminate or transfer any bacterial to the clean wound.

The right aseptic procedure is done by first washing the hands with soap, drying them com-

pletely before wearing the clean gloves. After the wound has been cleaned with gauze pad,

saline (a salt water solution) or a clean tap water, change gloves before applying the sterile

dressing such bandage or plaster. Because, during the dressing change, the gloves automati-

cally become dirty (Wysocki, 1989).

Wound dehiscence can be quite severe for the patient and it is also associated with a high

mortality rate. It happens due to poor tissue healing from malnutrition, obesity, anemia, in-

fection, premature removal of wound closure or stress on the unhealed incision such as strain-

ing or coughing. Thus, identification and appropriate management of the condition is key to

avoid infection. It can also be reduced by applying excellent surgical technique in each pa-

tient, prevention of pneumonia and wound infection. An excellent surgical team can also in

preventing SSIs. Significant others should avoid touching the operated part of the body when-

ever they visit the patient (Riou et al., 1999; Pavlidis et al, 2011).

In conclusion, surgical site infection can be prevented and managed by providing a clean envi-

ronment for patient, nurses and whole surgical team should following all the aseptic tech-

niques and good patient education before and after operation. All the prevention procedures

can easily be put into practice either in the hospital, nursing homes and even patients’ homes

as well.

5.3 Improving infection prevention

Patients have to be their own advocate in their own health care and think about their state of

health before and after being admitted to the hospital (Bodenheimer et al., 2002). Quality

19

initiative in the perioperative phase should be ultimate goal and without omitting any of the

aseptic techniques. Prophylactic antibiotics should be given within one hour prior to surgical

incision while normothermia is being given preoperatively. Compression stockings need to

worn in bed. Urinary catheter (flexible tube used to empty the bladder and urine in drainage

bag.

Also, it is used for measurement of urine output management of postoperative urinary reten-

tion however should be managed properly by removing it on day 3 to 6 as recommended to

avoid urinary tract infections (UTIs) unless the patient’s condition demands a longer stay.

Also, surgeons developing good closure techniques to avoid wound dehiscence is very im-

portant. Hair at the surgical site should be removed by depilatory methods and not with

blades (Page et al., 1993).

In providing a proper holistic care, patients themselves play a vital role in bettering care out-

comes. Obviously, the surgical patient is the primary holder of the bacteria and carries the

repercussion of the SSIs and should therefore be taught and guided on how to participate in

the prevention SSIs. Furthermore, patient self-care contributes a lot to quick recovery and

prevention of SSIs thus by having a good balance diet and daily activity since it helps with the

flow of internal oxygen. Smokers should quit smoking for couple of days to decrease the risk

of infection.

Postoperative wound care should be handled attentively. All the dressings for drainage and

closure should be checked closely to able to see any changes that is alarming in the post an-

esthetic care unit. More significance must be put on hand hygiene and strict asepsis during

changes. Monitoring of patients’ vital signs and keeping them warm as needed. Nurses should

carefully review postoperative plan with the patient and significant others to the level what

is written and said is understood.

Continuous education for whole surgical team (surgeons, nurses, anesthetists’ and clinical

support workers, patients and significant others) minimizes the risks of SSIs when recom-

mended measures are followed. Furthermore, follow up of all surgical wound patients espe-

cially patients who are host risk of SSIs for any possible postop infection to act upon as quick-

ly as possible if there is a rise of infection. According to Pavlidis, patients who are host risk

factors are already prone to infection and need more attention and special care to minimize

the risk of abdominal wound dehiscence occurrence.

6 Research question and purpose of the study

The purpose of the thesis is to describe what do nurses do to prevent infections in surgical

patients with abdominal wounds.

20

The research question of the thesis is “What do nurses do to prevent infections in surgical

patients with abdominal wounds?”

7 Thesis research method

Qualitative research is a type of scientific research that search for answers to a question,

systematically uses a predefined set of events to answer the question, gathers evidence, finds

conclusions that were not determined in advance, produces findings that are appropriate

beyond the direct limits of the study (Natasha Mack, Cynthia Woodsong, Kathleen M.

Macqueen, Greg guest, & Emily Namey, 2011). In this thesis the data was gathered by using

interview as the method. Qualitative interviews allow a researcher to naturally study the

individual lived experience of another (Brinkmann 2013, 47). The researcher also chooses the

concepts and how the data is collected, transcribed, analyzed and reported.

The number of participants in qualitative study is normally smaller compared to quantitative

study because quantitative aims for statistical generalization while qualitative deals with

finding solutions to past, present and future occurrence (Brinkmann 2013, 144). Therefore,

qualitative research method was the logical choice for this thesis as the purpose was to de-

scribe what nurses do to prevent infection in abdominal wounds. Qualitative research is nor-

mally analyzed with content analysis and it was used for this thesis. Inductive method deals

with the generation of new theory extracting from the data or looking at previously re-

searched situation from a different angle (Gabriel, 2013).

7.1 Data collection process

The data collection process began by first contacting the clinical teacher of the hospital

where the interview was conducted. The clinical teacher was contacted by the writers of the

thesis through email to get permission after the contract of the thesis was accepted by the

senior lecturer supervising the thesis. The writers of the thesis then proceeded with the writ-

ing of the thesis plan and after the plan was done, an abstract of the plan was sent to the

clinical teacher in June 2018 together with consent forms that needed to be filled and signed

by the writers of the thesis to get permission to do the interview at the hospital. The forms

were sent to the writers through email by the clinical teacher. It took about two months be-

fore a response came from the clinical teacher after the abstract of the thesis plan and the

consent forms were emailed.

21

In August 2018 permission was granted to conduct the interview and the contact information

of the interested participants were given to the writers of the thesis by the clinical teacher

for further communication. The participants willing to be part of the interview were first

contacted by the clinical teacher by briefing them about the thesis topic. The clinical teacher

helped to get four registered nurses from two different units. The interviewers’ main goal

was to know what nurses do to prevent infection in surgical patients with abdominal wounds.

Choosing the interview settings, structure, length, time, questions and way of recording were

also part of the planning. The interviewers and the interviewees fixed the time and place of

the interview together through email.

The participants were assured about the confidentiality and good ethical conduct of the writ-

ers in a covering letter (see Appendix 5). They were also assured about the confidentiality of

the interview and asked to sign consent form (Appendix 3) before interview. The interviews

took place in September 2018 and they were all approximately 30 minutes long. Both writers

of this thesis were present in every interview. During the interview session, the data was

collected by interviewing face-to-face four female registered nurses in a gastrointestinal unit,

two nurses from two different units. The participants were provided with the interview ques-

tions both in English and Finnish before the interview. The data collection process is demon-

strated in Figure 2.

Figure 2: Data collection process

22

7.2 Data collection

The method used in the thesis was a semi structured group interview. According to Powney

and Watts, an interview is a conversation between two or more people where one or more of

the participants takes the control for re-porting the substance of what is said. Qualitative

interview is normally used when researchers are keen to know people's experiences in the

past, language and communication, and culture and the society as whole (Brinkmann 2013,

47). With the nurses’ experiences and what they have been doing to prevent infection in sur-

gical patients with abdominal wounds will help the writers to get answers to the thesis topic.

This can demonstrate and help researchers to know about how a specific event did occur and

if there is a chance of the same thing occurring again. Individual interview is more effective

and flexible than group interviews. It also helps the interviewer to get more insight from the

topic being discussed (Chrzanowska, 2002). The interview was conducted in two separate

groups and it took about thirty minutes for each interview.

The participants in this study were four female registered nurses working in a unit of gastroin-

testinal surgery. The reason for choosing this target group was because nurses play an im-

portant role in the surgical patients with abdominal wounds. Participants were given free

time and good environment to be able to express their personal views based on their own

experiences. The participants chose to be interviewed at the hospital and the interviewers

agreed to it. As Marshall & Rossman (2006) also argue qualitative methods have three aspects:

Individual lived experience, society and culture, language and communication. The writers of

the thesis had also taken into consideration the language of communication both parties had

in common to be able to understand each other clearly during the interview without any mis-

understanding since the interviewees had Finnish as their first language and the interviewers

do not.

The interview took place in September 2018 and it was conducted at the hospital in a re-

served room (patient’s living room). The doors were locked to avoid disturbances during the

interview. The interviewees and the interviewers sat around a table facing each other. The

interviewers introduced themselves and briefed the interviewees about the thesis. Before the

interview began, the interviewees were asked to go through the printed questions again.

The interviews were recorded with one tape recorder and one of the writers’ just in case the

tape would not work. The recordings were loaded on both thesis writers’ computers for tran-

scribing them. The interviews were transcribed to be able to re-listen to them many times

and to make notes on the documents. Transcribing the data was done by the writers of this

thesis by listening to each interview recording and typing them down on separate files by

using Microsoft Word. It took about six hours depending on the length of the answers and lan-

guage, since some of the interviewees got stuck along the line and could not answer some

questions in English but Finnish rather. Translation from Finnish to English needed to be done

23

while re-listening to the audio tape over and over. Everything said by the interviewees were

transcribed by the interviewers. The files were named “Interview unit 6” “Interview unit 7”

and after the thesis was written, the recordings were erased.

7.3 Data analysis

Content analysis can be used either in an inductive or deductive way, inductive method was

used in this thesis. Firstly, the data collected from the interviews were transcribed by listen-

ing to the tape recorder many times in a word document. The word documents were printed

out to make it more manageable to find out the main findings relating to the research ques-

tion. Many similarities were found which were grouped by highlighting in different color keep-

ing the research questions in mind. In the meantime, simplifications of the long text were

also made. Two examples of simplifying raw data are shown in the Figure 3. For example, all

simplifications that expressed about educating patients were highlighted with green and

wound care with yellow. Grouping was done by writing down in paper following the same

color or data talking about the same topic.

Figure 3: Example of simplifying raw data The strategy was to develop a sub-category when the writer finds two or more similar simpli-

fications and avoid unnecessary things that didn’t correspond to the research question. The

formation of categories was all written down in paper making it easy to observe all simplifica-

tion altogether and to check it by moving forward and backward. Progression in development

of categories is established when moving categories back and forth (Mariette Bengtsson,

2016). Example of forming sub-category is shown in Figure 4.

--when patient is discharged from the

hospital, we give them instructions about how to pro-ceed if the wound

gets infected

Guidance is given to patients while being

discharge

Abdominal part of body, around it has

bacteria which increas-es the chance of infec-

tion

Sometimes body itself

is a carrier

24

Figure 4: Example of forming sub-categories Altogether eighteen subcategories were developed and after this, the best option was only to

develop generic category in order to make it less complicated for proceeding the next step of

developing main categories and to receive relevant main categories. Example of forming ge-

neric category is shown in figure 5. Depending upon the relationship between sub-categories,

eight generic categories were formed by combining seventeen sub categories and one of the

simplifications was left it out to sub category only as it couldn’t be included to higher catego-

ry.

Figure 5: Example of forming a generic category At the end, the four main categories were formed. Example of forming main category is given

in the figure 6. While developing main categories, writers made sure that the research ques-

tion are being answered through it. The writers need to discuss and view their opinions re-

garding the categorization (Satu Elo and Maria Kääriäinen, 2014). It took several hours for

both writers to agree on all categories. Formation of all categories are shown in Figure 8.

Guidance is given to pa-tients while being dis-

charge Guidance are given for follow up care

Guidance given about not using alcohols is given be-

forehand

Basic aseptic tech-niques are taught to

patients

we advise to avoid unnecessary touching

to wound

Guidance given dur-ing the hospital stay

25

Figure 6: Example of forming main category

Translation to English was done in the first phase already in order to have better understand-

ing as it was difficult to do so in Finnish language. Translation of Finnish to English was made

using internet and writer’s own knowledge, and no other individuals were involved. The ex-

ample for the translation of quotation is shown in figure 7. In the similar way other data were

also translated.

Figure 7: Example of Translation from Finnish to English

‘‘perehdys alussa annettu ohjeet haa-

vasta’’

Information about the wound is given during the orienta-

tion period

Instructions given after discharge

instructions given during the hospital

stay

Educating patients

26

Figure 8: All categories

SUB-CATEGORY GENERIC CATEGORY MAIN CATERORY

THE WOUNDS NEED TO BE DRY.

THE WOUND IS CHECKED ON DAILY

BASIS THREE TIMES A DAY.

WE USE WOUND BANDAGE ONLY WHEN IT’S SECRETING.

DRY WOUND HEALING

OBSERVANT DAILY WOUND CARE

AFTER 24 HOURS, WOUND BANDAGE IS OPENED

WOUND DRESS-ING

RISK OF INFECTION ARE HIGHER WITH OBESE AND DIABETES PATIENTS

DEMENTED PATIENT TOUCHES

WOUND WITHOUT ACKNOWLEDING IT

A GOOD BALANCE DIET IS ALWAYS NEEDED

MEDICAL HIS-TORY

CONSIDERING RISKS

WE ALSO DO NUTRITIONAL ANALYSIS

TEST

LACK OF NUTRI-ENTS

WE GIVE THEM INSTRUCTIONS FOR

FOLLOW UP CARE

WE PROVIDE THEM GUIDANCE FORMS WHEN THEY LEAVE FOR HOME

BASIC ASEPTIC TECHNIQUES ARE TAUGHT TO PATIENTS

INSTRUCTIONS GIVEN AFTER DISCHARGE

EDUCATING PA-TIENTS

WE ADVICE TO AVOID UNNECESSARY TOUCHING TO WOUND

INSTRUCTIONS GIVEN DURING THE HOSPITAL

STAY

FIRSTLY, BLOOD SAMPLE ARE EXAM-INED

ANTIBIOTIC TREATMENT IS STARTED

MEDICAL TREAT-MENT

FOLLOW-UP OF THE PROCEDURES

AFTER WOUND CARE

WE ADVICE PATIENT TO WALK AS MUCH AS POSSIBLE

SOME PATIENT END UP BEING BED RIDDEN DUE TO PAIN

MOBILITY

LACK OF MOBIITY ALSO AFFECTS

WOUND HEALING

WE DONT HAVE ANY WOUND CARE TEAM

27

8 Findings

The thesis’s purpose was to describe “What do nurses do to prevent infections in surgical

patients with abdominal wounds?”. The data was collected by interviewing four registered

nurses in two different wards. Interviews were analyzed using inductive content analysis.

Based on the analysis, four main categories were produced using inductive content analysis:

wound care in post-operative phase, risks taken in considerations, educating patients and

procedure followed after wound infection.

8.1 Observant daily wound care

This main category was formed by joining two generic categories, ‘‘dry wound healing’’ and

‘‘wound dressing’’ and four sub-categories which are illustrated in Figure 8. The ward didn’t

have a team that specifically take care of wound, but nurses and ward doctors are responsible

for patient’s wound care. Wounds are assessed by nurses every day and sometimes doctors as

well if needed. Antibiotics are important to treat postoperative infected wounds and it is

done under the prescription of doctors. Wounds are assessed regularly, evaluated and docu-

mented by nurses based on the healing process. Holistic assessment of the patient is an im-

portant part of the wound care process as well as keeping a healthy diet. Proper wound dress-

ing always comes first during wound care. Use of sterile medical tape, gloves and bandages.

Wounds are covered with a bandage or gauze dressing and should be changed daily if needed.

Nurses ensure that all workers follow all the hygiene techniques when taking care of infected

wounds. Enhancing patient outcomes and promoting fast wound healing is one of nurses’ par-

amount goal. In addition, keeping the wound clean and dry is also one major factor nurses put

into consideration when taking care of infected wounds. Clean environment helps in preven-

tion of infection and since patient’s environment is a major reservoir of microorganisms,

cleaning personnel are trained about the right chemicals to use when cleaning patient´s

room. Nurses also explained that patients themselves are always involved in every plan they

figure out for the further care.

“Ei koskaan koske haava.’’

‘’Never touch your wound without any protection.’’

8.2 Considering risks

Two generic categories ‘‘medical history’’ and ‘‘lack of nutrients’’ developed second main

category which was followed by four sub-categories. The names of the sub-categories are

represented in Figure 8.

28

Preoperative patients and postoperative patients are being taken care of in the same ward by

the same nurses, and if proper hand hygiene is not followed strictly by the nurses and the

patients, it becomes so easy for a postoperative patient to get an infection from preoperative

patient and vice versa. If the nurses don’t follow the correct aseptic, a patient awaiting sur-

gery might also get infected during the waiting time.

Further, nurses explained that factors such as: poor tissue healing from malnutrition such as

anorexic patients, poor medical history, obesity, smoking, alcoholic, dementia patients, and

lack of mobility, premature removal of wound closure or stress on the unhealed incision like

coughing are taken in consideration in wound care.

Malnutrition (anorexia) is very well known in younger patients and sometimes in adults as

well. Malnourished patients take time to heal due to weak immune system. There are occa-

sions younger refuse to eat the meal offered to them during their stay in the hospital be-

cause, they fear to gain weight. And as a result of this, most end up being at risk of infection.

Therefore, nurses are always making sure that patients are getting enough nutrients.

“Dementia patients with bad hygiene keep touching the wound because they end up forget-

ting that wound should not be touched when hands are not clean and some patients end up

taking off the bandage before the 24hrs time...”

8.3 Educating Patients

Third main category was developed by combining two generic categories ‘‘instructions given

after discharge’’ and ‘‘instructions given during the hospital stay’’ and four other sub-

categories. These sub-categories are shown in Figure 8.

Patients are educated on the prior or on the day of discharge about wound care. There cases

some patient would rather want to be discharged before time. The education is mostly about

hygiene and mobility. Anything unsterile that goes into the wound can cause infection espe-

cially if the wound has not been healed to a certain process. Sometimes patients do not un-

derstand the importance of mobility, so they end up becoming bed radiant with the excuse of

pain. Patients who are clients of home care service are provided with clear written instruc-

tions about the wound that need to be followed by the nurses when they go to various home

to provide care. There are occasions whereby home care nurses call the hospital if the writ-

ten instructions are not clear or when the wound does not seem to heal.

“Patients are educated about wound care because most of them think the wound is healed

and everything is fine that is why they are being discharged”.

“The patient must be walking as much as possible.’’

29

It is the responsibilities of the nurses to educate significant others about how wound should

not be contaminated in cases whereby the surgical patient has dementia, Alzheimer, alcohol-

ic, etc. or when a patient will intentionally will not want to follow the instructions given to

be take home. This happen quite often with older patients who think they have lived more

enough.

“When discharging a patient, it’s very important to give them verbal and written infor-

mation”

8.4 Follow-up of the procedures after wound care

Last main category was developed firstly by combining five sub-categories to form two gener-

ic categories ‘‘medical treatment’’ and ‘‘mobility’’. The process of categorization is shown in

figure 8.

The procedure followed in the ward after the wound is infected starts with the bacteria tests

prescribed by a doctor. Based on the type of bacteria, doctors start antibiotic treatment, and

it also depends upon type of wound that patient has. Wound is checked constantly by the

doctors and nurses daily.

Cleaning of the wound and basic hygiene is strictly needed to be followed to prevent further

complication. Nurses had many cases where the infection of the wound made patients to stay

longer at hospital. The nurses also mentioned about the most common equipment used in the

ward for the infected wound known as vacuum-assisted closure (VAC). A VAC machine is used

to drain secreted wound after it has been infected. The VAC machine is similar to suction

machine and helps remove pressure over the area of the wound.

The machine helps wound heal more quickly by draining excess fluid from the wound, reduces

swelling and bacteria in the wound, keeps wound moist and warm, helps draw together

wound edges, increases blood flow to the wound and decreases redness and inflammation.

Some other factors mentioned in the interview were mobility and nutrients. Nurse explained

the importance of mobility for faster healing process of wound infection. For example, walk-

ing as much as possible and not just lying in a bed. Good balance diet is always important

after surgery. Especially with malnourished patients and patients lost a lot of blood during

the course of the surgery. The nurses recommended the use of supplements since patients

need energy after surgery, during the wound healing process and also due to blood loss in the

intraoperative phase. Patients’ BMI are checked on regular basis. When a patient is dis-

charged a form is given to be fill in incase the wound gets infected at home.

“Monesti infektiot ilmeinen vasta potilas lähtee kotiin, kun hoidetaan meille lyhyt sitten, me

annettaan ohjeet miten hän voi ette seurata siitä haava, jos alkaa tulehdus.’’

30

“Often patient gets infection after getting discharged, we give them instruction for the fol-

low up care.’’

“Patients are given Nutridrink 2-3 times a day after doctors’ prescription”.

“After 24 hours, bandage should be removed to check the wound if there is any secretion”.

9 Discussion

9.1 Discussion of the findings

The purpose of the thesis was to describe what nurses do to prevent infections in surgical

patients with abdominal wounds. The research question of the thesis was “What do nurses do

to prevent infections in surgical patients with abdominal wounds?” Four female nurses shared

their experiences regarding the abdominal wound care. The recordings received from the

interview was played many times, using the inductive content analysis and it was categorized

into four topics. Thus, the purpose of the thesis and the research question was established.

Talking of the interview, the four nurses had almost the same experiences and knowledge

about abdominal wound care even though two of them have not been working in the nursing

field for long compared to the other two nurses. The process the nurses follow to prevent

infection during postoperative care is also connected to the pre-operative phase. During the

course of the interview, the nurses were more prepared, and all the questions were asked in

a professional way. Because of their busy schedules, the writers decided not to put any pres-

sure on them but rather, waited for them to give us a convenient date, time and place of

their own whenever they are ready to be interviewed. The nurses seemed really prepared as

all answers were answered professionally. All the answers given really showed that their

knowledge about abdominal wound infection is deep due to their experiences.

Also, the nurses pointed out that during hospital stay and before discharge, they educate

patients and significant others about wound care especially on how not to contaminate the

wound. This signifies that, patients’ wellbeing and safety is of importance to them. It also

tells the empathy they have for their patients. The prevention procedures that the writers

found out are very simple and easy to be followed in all the healthcare centres and in homes

as well. Majority of surgical site infections is preventable if the right procedures being taught

are followed accordingly. One of the nurses showed the writers of the thesis how PICO ma-

chine works because she talked about it during the interview. Luckily, there was a patient

using the machine. Before the PICO machine was showed to the writers, the nurse had to ask

permission from the patient whose wound has been infected and needed to be treated by the

machine. The patient gave the permission and was not bothered while the nurse was showing

the writers how the machine drains the secreted wound. After everything was done, the writ-

ers thanked the patient for collaborating.

31

There were some challenges the writers faced during the writing of the thesis. Firstly, a

permission letter needed to be sent to the hospital for approval before the writers could pro-

ceed with the thesis. A reply was received after a month by the clinical teacher at the hospi-

tal that, the letter and the questionnaires should also be in Finnish language and not only in

English. It took the writers more than a week before the letter was translated from English to

Finnish since both writers of the thesis are international students. After the letter and other

forms that needed to be fill and signed by the writers was emailed to the clinical teacher

before the hospital approves, it took some time before the clinical teacher replied and that

was when a reminder email had been sent to her. The writers of the thesis were told even

though everything has been approved, registered volunteer nurses to participate in the inter-

view are lacking due to their busy schedules.

The clinical teacher later asked the writers if they have other options to complete their thesis

in case no one volunteers to participate. The reply was there is no other option, so she should

try her best and get the writers a minimum of four nurses. Finally, one registered nurse vol-

unteered and after some weeks, three more nurses volunteered as well and that was how the

writers got four nurses to participate in their final project. Another major challenge was tran-

scribing the Finnish part of the data as mentioned earlier on both writers are international

students. In all it took about four months before everything was done starting from getting a

permission from the hospital to interviewing the four registered nurses. The clinical teacher

asked a copy of thesis once it is completed.

The findings of this study showed that, infection can be prevented when all the aseptic tech-

niques are followed accordingly by the health care workers and patients. The researchers

have gained more insight about surgical site infections and at the same time, the preventive

measures that need to be taken to prevent infection starting from preoperative phase to the

postoperative phase. In our opinion, the prevention methods are very wide and simple to

follow if they are put into practice. In addition, some of the references in this thesis are very

old and the care practices may have changed. Therefore, the trustworthiness is not very

tight.

9.2 Ethical considerations of the thesis

According to Ezzy (2002, p72), ethics in research is an essential matter which must be put

into consideration in order to protect the rights of the participants. Beginning from the in-

formed consent, confidentiality and guaranteed anonymity, voluntary participation with the

right to withdraw at any time, the role of the researcher, not twisting data and loyalty.

Smeltzer and Bare (1992, p50), defines ethics as the philosophical study of morality, and one

relies on formal theory rules, principles, or codes of conduct to determine the “right” course

of action. Transparency plays a vital role as well as communicability in ethical consideration.

32

In other words, researchers must be able to communicate in clear manner that readers get a

clear understanding without any misinterpretation of the study (Auerbach & Silverstein 2003,

50).

A cover letter was attached to the thesis plan, direct to the clinical teacher to gain her con-

sent from the participants (Appendix 4). And approval to conduct the research was given from

the head nurse of the department. A second letter was also sent to the participants also

known as the volunteer interviewees informing them about the thesis, with the assurance of

not revealing their identity to a third party (Appendix 5 and 6). Furthermore, questionnaire

was given on the day of the interview. The language of the interview was English but was also

be answered in Finnish language as well. The clinical teacher gave us the permission to con-

duct the interview and also emailed us all the necessary forms that needed to be filled and

signed.

Conducting research requires, confidentiality, honesty, integrity and diligence. All the par-

ticipants of the thesis were kept anonymous and the data collected was kept confidential.

The writers’ practiced right to autonomy and confidentiality after obtaining the signed con-

sent form of the participants. The whole thesis process followed Laurea guidelines that are

set by Laurea University of Applied Sciences. The thesis topic was approved during the thesis

meeting together with other students and later, the topic analysis was also approved by our

supervising and tutor lecturer. Ethical considerations were built from the topic of the thesis

to the publication of the thesis (Burns and Groove 2001, 191).

9.3 Trustworthiness of the thesis

Polit & Beck (2010. p 492), has described the four-category credibility, dependability, con-

firmability and transferability suggested by Lincoln and Guba (1985) for developing the trust-

worthiness of a qualitative study. Credibility is defined as the truthiness of the data that are

interpreted; dependability refers the reliability of data over any other conditions; confirma-

bility interprets focusing on the interviewees’ thoughts and experiences rather than own

views; lastly transferability refers to produce findings in a way so that other researchers can

interpret for similar settings (Polit & Beck, 2012 p492). All these four categories were as-

sessed during the whole process of writing a thesis.

The authors explained only the data provided by the participants of the interviews, reflecting

their views and opinions in details, avoiding bias while interviewing. Trustworthiness has been

put in all areas starting from the choosing the topic and research questions to research meth-

od to planning, to the implementation, to the evaluation and the publication by a mutual

understanding and communication between both the authors and the tutors. While choosing

the research method, options were created in which qualitative method was the best way to

33

achieve finding for the chosen research question. The participants were informed before-

hand, but the interviews questions were shown to them on the day of the interview.

The guidance of the tutors was also highly taken in consideration in the process of writing the

thesis. The writers have provided sufficient information about the whole thesis; describing

the study in a well detailed way for readers to be able evaluate it. This thesis has evaluated

the trustworthiness by using the methods mentioned above; by also evaluating each aspect of

the thesis and looking at its trustworthiness (Elo & Kyngäs., 2007)

Trustworthiness is an important fundamental principle to qualitative research. It is showed by

the findings portraying the reality of the experience. As said by Auerbach and Silverstein

(2003, 60), trustworthiness should be able to relate to the purpose and case to the study.

When assessing trustworthiness, the purpose and length of the study, the researcher’s com-

mitment and relation-ship between the informant, data collection, data analysis, reliability

and lastly reporting the analysis should all be evaluated (Auerbach & Silverstein, 2003, 58).

In all, the trustworthiness of this study has been put into consideration throughout the whole

study. Because surgical site infection is a very wide topic and can be discussed from different

angles. The purpose of the study is to describe how nurses prevent abdominal wound infec-

tions.

9.4 Conclusions and recommendations

In conclusion, the results of the research show that surgical site infection can be prevented if

all the aseptic techniques are follow correctly starting from the preoperative phase to the

postoperative phase. Nurses, surgeons, ward doctors and cleaning personnel have pivotal role

to prevent infection as they deal with surgical patients. A clean environment is always the

first step to begin with when dealing with wounds. Also, nurses play a major role by educating

patients about good hygiene before, during and after surgery. Surgical site infection is a very

broad topic and can be discussed from different angles.

Based on the findings of the thesis, following recommendations are made. First the hospital

didn’t have infection control team but rather surgeons, ward doctors, nurses, students and

sometimes patients themselves prevent infection which is a good idea but if a team of nurses

are specifically trained about abdominal wound infection, it would be easier for the nurse

who has been trained to detect when a wound is about to be infected. Also, this would make

nurses work easier since a nurse who has not had special training about abdominal wound

would only take of clean wounds whilst the nurse who has extra training wound infection will

take care of infected wounds. This procedure will also help in the prevention of infection.

Secondly, simple and readable posters talking about infection prevention should at the hospi-

tal surroundings so that incoming and outgoing visitors can read and enlighten themselves

34

about infection. Surgical site infection has become one of the most leading cause of hospital-

ized postoperative patients, financial loss to families and the country as a whole. Basic

knowledge of aseptic techniques and its applications can help decrease infection.

Also, patients with infected wounds should be isolated from patients with clean wounds. This

method can prevent the spread of infections among patients since the ward does not consists

of postoperative patients only but preoperative patients as well. Since the interview was con-

ducted in patients’ living room and door had to be locked to prevent a patient from entering

during the interview. The writers of the thesis will recommend if the hospital gets a separate

spare room where doctors, nurses and significant others can meet and discussion about pa-

tient’s continuous care.

35

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40

Table

Table 1: Types of surgical site infection……………………………………………………………………16

41

Figures

Figure 1: Cross-section of abdominal wall depicting CDC classifications of surgical site

Infection...............................................................................15

Figure 2: Data collection process................................................................21

Figure 3: Example of simplifying raw data.....................................................23

Figure 4: Example of forming sub-categories..................................................24

Figure 5: Example of forming generic category................................................24

Figure 6: Example of forming main category...................................................25

Figure 7: Example of Translation from Finnish to English.....................................25

Figure 8: All categories.............................................................................26

42

Appendices

Appendix: 1 Factors Influencing Surgical Infections............................................43 Appendix: 2 Chain of Infection....................................................................44 Appendix: 3 Consent form for Participation in Interview......................................45 Appendix: 4 Cover letter for the ward manager.................................................46 Appendix: 5 Cover letter for the participating nurses/interviewees.........................47 Appendix 6: Cover letter for the participating nurses/interviewees in Finnish.............48

43

Appendix: 1 Factors Influencing Surgical Infections

According to Nichols (1998) perioperative infection are caused by many factors such as the

length and type of surgery, the surgical team, history of the patient etc.

PATIENT VARIABLES PRE-OPERATIVE

PHASE

INTRA-OPERATIVE

PHASE

POST-OPERATIVE

PHASE

Chronic disease Prophylatic

antibiotic

Type of surgery Hand washing

Age Surgery Surgical technique Asepsis principles

Immunosuppressive

drugs

Skin preparation

clipping/showering

Skin-closure

techniques

Proper wound man-

agement(dressing)

General physical

condition

Patient length of

hosptilization (ward)

Duration of surgery Mobility and pain

control

Skin condition Catheterization Extent of tissue loss Adequate wound

discharge

Nutritional Time intervals Environment

Infection Patient length of

hosptilization (ward)

Early discharge

Overweight

Hydration

44

Appendix: 2 Chain of Infection, Ziegler M. (2010)

SUSCEPTIBLE HOST Immunosuppres-sion Diabetes Surgery Burns Elderly

INFECTIOUS AGENTS

• Bacteria

• Fungi

• Viruses

RESEVOIRS

• People

• Equipment

• Water

PORTAL OF ENTRY

• Mucous membrane

• G I tract

• G U tract Respiratory

MEANS OF TRANS-MISSION

• Direct con-tact

• Ingestion

• Fomites

• Airborne

PORTAL OF EXIT

• Excretions

• Secretions

• Skin

• Droplets

45

Appendix: 3 Consent form for Participation in Interview

I, hereby, agree to participate in this individual interview. I understand that the interview is

part of bachelors’ thesis, “Infection prevention in surgical patients with abdominal wounds”

by Manisha Udash and Doris Appiagyei Agyare.

• I understand that I am participating in the thesis project for bachelor’s degree.

• I understand that no payment will be made for the participation.

• I understand that I can withdraw anytime if I do not want to continue with the inter-

view.

• I understand that I have right to decline answering any questions that I am not com-

fortable with.

• I understand that the interview can take up to 60 minutes.

• I understand that the interview will be recorded.

• I give permission to record my thoughts that I put during the interview.

• I understand that my name will not be mentioned in the thesis or any report made

based on this interview.

• I understand that this thesis project will be reviewed and approved officially.

• I have read and understood the explanation provided to me. I have had all my ques-

tions answered to my satisfaction, and I agree to participate in this study.

My Signature, ____________________________

Date ____________________________

Manisha Udash Doris Appiagyei Agyare Sari Haapa

Nursing Student Nursing Student Thesis Tutor, Senior Lecturer

Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi

Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi

46

Appendix: 4 Cover letter for the ward manager

Dear Ward Manager,

We are graduating nursing students in Degree programme in English from Laurea University of

Applied Sciences. As thesis is part of the requirement of our study programme, we have cho-

sen a topic ‘’Infection prevention in surgical patients with abdominal wounds’’ We chose this

topic because infection is one of the most pressing issues whenever a surgical operation is

involved. Infection end up causing overstay in the hospital, loss of money for the patient and

sometimes to the hospital as well due to long awaiting queue.

We kindly request for your permission to undertake our thesis in your ward and we will also

need your assistance in finding six English speaking registered nurses in the surgical ward,

who will assist with our questions. Interviews will be conducted in two or three groups or

individually if needed in a separately agreed place within their schedules. The interview will

take about 30 minutes.

The identity of the interviewees is only known to the writers of the thesis and will not be

revealed at the final presentation and publication of thesis. We commit to the obligation of

confidentiality and to adhere to good research ethics methods of writing the thesis. And un-

der no circumstances will there be a breach of contract.

Lastly, the theses of universities of applied sciences are published on Theseus.fi database and

if you wish, we can send you a link to our final thesis. We do hope that you grant us the per-

mission to carry out our thesis at your ward. Our contact is below in case you or the nurses

would like to reach us beforehand;

Doris (0469567482)

Manisha (0453113100)

Kind regards,

Manisha Udash Doris Appiagyei Agyare Sari Haapa

Nursing Student Nursing Student Thesis Tutor, Senior Lec-

turer

Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi

Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi

47

Appendix: 5 Cover letter for the participating nurses/interviewees

Dear Nurses,

We are graduating Nursing students in English programme at Laurea University of Applied

Sciences. Thesis is a part of our studies and our thesis topic is ‘’Infection prevention in surgi-

cal patients with abdominal wounds’’. Your personal experience of taking care of wounds and

preventing wound infection is of paramount importance. The results of the thesis may help to

improve wound care management.

The data will be collected by a semi structured interview. Interviews will be conducted in two

or three groups or individually if needed in a separately agreed place within their schedules.

The interview will take about 30 minutes. The interview language is English, but answers can

be can be given in Finnish language as well. If possible, we hope to conduct the interviews in

June or July. The interview will last about 30 minutes. We kindly ask you to participate in the

interviews related to the thesis.

Participation in the interview is voluntary and can be interrupted at any time. The interview

will be recorded, and the tape will be used only for the thesis. Interview material and the

recordings are kept so that only the authors of the thesis have the opportunity to see or listen

to them. The data will be erased after completing the thesis. The identity of the interviewees

is only known to the writers of the thesis and cannot be identified of the final thesis. We

commit to the obligation of confidentiality and to adhere to good research ethics methods of

writing the thesis.

The theses of the universities of applied sciences are published on Theseus.fi database and, if

you wish, we can send you a link to our final thesis. We hope that you will take part in the

interview. You can give your consent to the interview by signing the consent paper when we

meet. We have also given our contact to the ward manager and if you have any questions

about our bachelor's thesis, do not hesitate to contact us. We will be very delighted to answer

you before we meet in person. Getting the privilege to learn more from you will create

awareness for us and other nurses.

Kind Regards,

Manisha Udash Doris Appiagyei Agyare Sari Haapa

Nursing Student Nursing Student Thesis Tutor, Senior Lec-

turer

Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi

Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi

48

Appendix 6: Cover letter for the participating nurses/interviewees in Finnish

Hyvät hoitajat,

Olemme viimeistä vuotta opiskelevia sairaanhoitaja opiskelijoita englanninkieliseltä kurssilta

Laurea ammattikorkeasta. Oppinnäytetyö on osa opintojamme ja sen aiheena on "Tulehdusten

estäminen potilailla joilla on vatsan alueen leikkaushaava."

Teidän kokemuksenne leikkaushaavojen tulehduksien estossa on erittän tärkeä. Tämä

oppinnäytetyö toivottavasti tulee parantamaan haavojen hoitoa tulevaisuudessa.

Tiedot tullaan keräämään puolimuodollisella haastattelulla. Haastattelut tehdään

pienryhmissä aikataulujen niin salliessa, enintään 3 henkeä kerrallaan, haastattelu kestää

noin 30min. Haastattelu tehdään englanniksi mutta vastaukset voidaan antaa suomeksi myös.

Toivomme että haastattelut voidaan tehdä heinä- elokuussa. Pyydämme ystävällisesti, että

mahdollisimman moni osallistuisi haastatteluihin.

Osallistuminen haastatteluihin on vapaaehtoista ja voidaan keskeyttää milloin tahansa.

Haastattelut tallennetaan ja tallenteita tullaan käyttämään vain oppinnäytetyön tekemiseen.

Tallenteet poistetaan, kun oppinnäytetyö on valmis, haastateltavien henkilöllisyyttä ei tule

tietämään kukaan muu. Kaikki vastaajat anonymisoidaan oppinnäytetyössä. Me lupaamme

noudattaa luottamuksellisuutta ja hyvää tutkimus etiikkaa tehdessämme oppinnäytetyö.

Oppinnäytetyö tullaan julkaisemaan www.theseus.fi sivulla ja jos haluatte voimme lähettää

teille linkin valmiseen teokseen. Toivomme että osallistutte haastatteluun ja annatte

suostumuksenneallekirjoittamalla suostumuslomakkeen jonka annamme ennen haastattelua.

Olemme antaneet yhteystietomme osaston johtajalle, jos teillä on kysymyksiä

opinnäytetyöstämme älkää epäröikö kysyä. Vastaamme kysyksiinne ennen tapaamista. On ilo

päästä oppimaan lisää ja tuottaa lisää tietoisuutta kaikille hoitajille.

Ystävällisin terveisin,

Manisha Udash Doris Appiagyei Agyare Sari Haapa

Nursing Student Nursing Student Thesis Tutor, Senior Lec-

turer

Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi

Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi