16 JCN 2016, Vol 30, No 5

Since 2005, the pace of innovation in surgical techniques has meant a

45% increase in patients receiving surgical procedures to manage a variation of medical conditions (NHS Confederation, 2016). This equates to approximately nine million surgical procedures (NHS Confederation, 2016), while a survey across five NHS Trusts in England revealed that within the community setting surgical wounds represented 13% of wound types (Ousey et al, 2013). This indicates that the prevalence of surgical wounds in the community may have a significant impact on a nurse’s caseload, particularly where they are not treated appropriately.

Most surgical procedures do not result in complications, however, no operation is entirely without risk. Any intervention aimed at preventing complications should involve the identification and reduction of risk factors, such as surgical site infection (SSI), and the establishment of an optimal patient environment to

Managing postsurgical wounds in the patient’s home

facilitate healing. This article will look at the post discharge complications and best practice treatment options of surgical wounds within the community setting.

WOUND HEALING

The normal healing process is a complex series of biological and chemical events that can be divided into four distinct overlapping phases (Hart, 2002): Haemostasis: the body’s response

to blood vessel trauma and

Kirsty Mahoney, clinical nurse specialist, wound healing, Cardiff and Vale UniversityHealth Board

Many community nurses will have to attend patients that have a surgical wound. The desired clinical outcome for any surgical wound will be to achieve closure and skin integrity with an acceptable cosmetic result, and to avoid any complications. Patients presenting to community nurses after discharge from hospital may well have experienced postoperative complications or may be at risk of complications following suture removal. Community nurses should be aware of wound problems that may arise following surgery and how to address them appropriately.

KEYWORDS: Wound care Surgical wounds Pain Surgical site infection

Kirsty Mahoneybleeding, involving platelets and blood clotting proteins working to stem blood flow

Inflammation: a self-protective response where white blood cells remove harmful stimuli such as damaged cells or pathogens

Proliferation: this stage involves a range of changes including angiogenesis (formation of new blood vessels), collagen deposition, growth of granulation tissue and epithelialisation

Maturation: the final stage of wound healing where collagen fibres cross-link with each other and proteins to increase the strength of the new scar tissue (Bryant and Nix, 2012).

The progress of wound healing is usually uncomplicated (Enoch and Leaper, 2005) and should be competed within a timely manner, i.e. 4–6 weeks. Wounds are usually classified as acute or chronic, and this is largely dictated by how long the wound has been present, for example, wounds that heal within the 4–6-week period without being negatively

WOUND CARE

Figure 1.Wound closure using staples.

Figure 2.Wound closure using stitches.

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juxtacures® Adjustable measurable compression device to heal venous leg ulcers

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18 JCN 2016, Vol 30, No 5

healing. Interventions can be put into place to address any potential risk and optimise the patient’s systemic environment.

The following circumstances may increase the patient’s risk of complications: Age: the skin thins and loses its

elasticity as people age; the body’s cellular repair function also declines. Conversely, younger patients may have an immature immune system, which increases risk of infection (Bryant and Nix, 2012)

Poor nutrition: during and after surgery patients can quickly become depleted of essential nutrients due to long periods without food and drink, or lose protein and nutrients through highly exuding wounds (Vuolo, 2009). Inadequate nutrition can effect immune function, collagen synthesis and alter tensile strength, which are essential for supporting wound healing and, if not adequately addressed, can lead to slow or impaired healing (Quain and Khardori, 2015)

Obesity: adipose tissue (which stores fat) is avascular and can reduce blood flow to the skin (Vuolo, 2009)

Predisposing comorbidities: conditions such as diabetes, peripheral vascular disease and anaemia, for example, can result in a poor vascular supply

Some medications such as steroids and chemotherapy agents act as immunosuppressants and may affect the body’s ability to combat infection( Vuolo, 2009). Steroids have also been shown to reduce macrophage infiltration and reduce tensile strength, which may impede healing (Wang et al, 2013).

WOUND CARE

influenced by any underlying aetiology such as diabetes are usually classified as acute. Surgical wounds usually fit into this classification and a wound audit in one NHS trust indicated that 70% of surgical wounds had healed within six weeks (Drew et al, 2007).

SURGICAL WOUNDS

There are several methods of closing a surgical wound, including staples or clips (Figure 1), sutures (Figure 2), adhesive tapes and skin adhesives (Bryant and Nix, 2012).

The method chosen will often

depend on the surgeon’s preference, the anatomical location of the wound and the tissue type involved ( Vuolo, 2009). Sutures should not remain in-place for longer than 7–14 days, however, this does depend on their anatomical location. Facial wounds, for example, usually require sutures to be removed after seven days, while abdominal and lower limb wounds should be left in place for 10–14 days (Wu, 2006). Sutures that have been left in for too long can cause skin reactions and scarring, while removing them too soon can lead to wound dehiscence (where the wound ruptures along a surgical incision) (Bryant and Nix, 2012).

Surgical wounds may be closed following surgery and heal by primary intention or, if infection is present, they may be left open to heal by secondary intention (Figure 3). Wounds that have a high bacterial load often breakdown if re-sutured, therefore Franz et al (2008) suggested that surgical wounds with a high bacterial load should be left open to allow free drainage of pus and exudate.

PATIENT ASSESSMENT

The main goal of managing a patient with a surgical wound is to prevent complications such as infection. This can be achieved through proper assessment of the patient, identifying potential risk factors, such as bowel surgery, anatomical location of the wound, and the patient’s nutritional status (see Table 1), that may deter

Red Flag Infection

It is important to remember that normal signs of the inflammatory phase of wound healing, including redness, swelling heat and pain, should not be confused with wound infection. Assessment of the patient and recognising how long the wound has been present will assist in differential diagnosis and may be used in conjunction with investigations such as wound swabbing and blood tests (such as full blood count [FBC] and C-reactive protein [CRP], which measure general levels of inflammation in the body). A raised white cell count and CRP are suggestive of wound infection (World Union of Wound Healing Societies [WUWHS], 2008).

Table 1: Basic elements of a surgical wound assessment

Patient-related factors Wound-related factors

What type of surgery was undertaken? Bowel surgery or contaminated surgery carries higher risk of infection

Anatomical location of wound

Underlying comorbidities that may affect healing, e.g diabetes, anaemia, low albumin, poor vascular supply

Length, width, depth and any undermining present

Was the patient acutely unwell before or following surgery?

Tissue type in wound bed

Nutritional status and BMI Exudate volume and colour of exudate

Medication that may have an impact on healing, e.g steroids or chemotherapy

Any signs and symptoms of infection present?

Pain

Condition of surrounding skin

Figure 3.Wound healing by secondary intention following dehiscence.

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WOUND CARE

20 JCN 2016, Vol 30, No 5

may need to be addressed to optimise the patient’s potential for healing and will include: Patient-related factors: including

comorbidities (e.g. diabetes), medication, nutrition

Wound-related factors: including size of the wound, position of the wound, tissue in the wound bed, presence of infection, exudate, pain, odour and condition of the surrounding skin.

Haematoma formation Haematomas (classed as an abnormal collection of blood outside a blood vessel) (Figure 4) can form as a result of anticoagulation therapy given after surgery to prevent complications, such as deep vein thrombosis (DVT) (Franz et al, 2007) or trauma during surgery.

The size of the haematoma will guide management; smaller haematomas may disperse on their own, however, larger examples may

antibiotics or topical antimicrobial dressings or a combination of both (according to local formulary and policies). Treatment decisions will depend on patient-related risk factors (e.g. comorbidities such as anaemia or diabetes), type of surgery and the anatomical position of the wound. Deep incisional or organ/space infections may require hospital admission and treatment with intravenous (IV) antibiotics.

Dehiscence Infection can have a significant impact on wound healing, with the presence of excess bacteria increasing patients’ metabolism and competing for the nutrients and oxygen required for wound healing (Bryant and Nix, 2012). Bacteria can also prevent the formation of new blood vessels and collagen within the wound bed, leading to dehiscence (Oldfield and Burton, 2009). Dehiscence may also occur if there is excessive strain on the incision site or if the wound is of poor tensile strength (Vuolo, 2009). Should a wound dehisce, it is essential that adequate assessment is undertaken to guide decision-making surrounding appropriate treatment and to assist in selecting a suitable dressing product. Assessment will identify any underlying issues that

COMPLICATIONS OF SURGICAL WOUNDS

Surgical site infectionsSSIs are the most common complication of a surgical wound and can lead to wound dehiscence if not addressed. SSIs accounts for 16% of all identified healthcare-acquired infections (Public Health England [PHE], 2012), and infection rates can be influenced by the type of procedure and are usually higher in large bowel surgery (PHE, 2012).

SSIs can occur at up to 30 days postoperatively (Bryant and Nix, 2012) but are most commonly identified between five to 10 days postoperatively (National Institute for Health and Care Excellence [NICE], 2008). Prompt recognition is essential to prevent further development, which can lead to serious consequences such as organ failure and death.

Other potential factors to consider are the increased financial burden and inverse impact on patients’ quality of life (NICE, 2008). Table 2 describes the three levels of SSIs that can occur (NICE, 2008), ranging from superficial to deep and organ/space infection.

Superficial SSIs are usually managed within the community and can be treated with either oral

Table 2: Levels of SSI

Level of SSI Signs and symptoms

Superficial SSI: affects skin and subcutaneous tissue Redness, pain, local swelling, heat, pus

Deep incisional SSI: affects the fascia and muscle layer Purulent discharge, fever, wound tenderness, pain

Organ/space infection: affects areas other than the incision site, e.g. joints/organs

Pus, abscess formation

Table 3: Dressing properties required according to TIME framework (Dowsett and Ayello, 2004)

Wound bed Property of dressing required

T = tissue type: granulation devitalised tissue (slough/necrosis/haematoma)

Protect granulation tissue Debride

I = infection Reduced bacterial load

M = moisture balance (excessive exudate) Absorption and prevention of maceration

E = edge (non-advancing or undermining) May require reassessment and referral to tissue viability or back to surgeon

Use of advanced therapies such as negative pressure wound therapy (NPWT)

Figure 5.Surgical wound with moisture imbalance (maceration to surrounding skin) and non-advancing edge with undermining.

Figure 4.Postoperative haematoma.

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22 JCN 2016, Vol 30, No 5

WOUND CARE

require surgical debridement and could lead to wound dehiscence and infection (Oldfield and Burton, 2009).

PainPostoperative pain can be experienced up to two weeks following surgery for a closed wound (Apfelbaum et al, 2003). Pain is very much an individual experience and will depend on how a particular patient responds; where the wound is; tissue type; and whether infection is present. Unresolved pain may lead to poor wound healing (Bryant and Nix, 2012), while pain experienced at dressing changes can mean patients become resistant to treatments recommended in the future.

Pain should be assessed using locally available pain assessment tools, such as a visual analogue scale (VAS), where patients pinpoint their pain experience on a vertical line anchor at each end with verbal descriptors ( ‘no pain’ and ‘the worse pain imaginable’, for example) (Hawker et al, 2011), with analgesia prescribed and its effectiveness monitored accordingly.

CARE OF THE SURGICAL WOUND

Postoperative wound cleansingGuidelines from NICE (2008) suggested that saline should be used for wound cleansing up to 48 hours postoperatively (should cleansing be required). Ideally, dressings should be left intact for 48–72 hours to allow wound epithelisation (NICE, 2008), and wound cleansing would only be advocated before this due to excessive exudate appearing on the dressing or if wound dehiscence occurred. After 48 hours, patients may shower if their wound is intact. Should the wound dehisce or require cleansing after 48 hours, potable tap water is considered appropriate.

Postoperative dressingsIt has been suggested by NICE (2008) that postoperative wounds should be covered with an ‘appropriate interactive dressing’. However, this is very subjective and does not offer very much information about what an appropriate interactive dressing consists of.

In the author’s clinical experience, an ideal postoperative dressing should possess the following characteristics: Prevent contamination Allow inspection of the wound,

i.e. have a see-through element to allow for monitoring of progress

Be non-traumatic on removal Maintain a moist wound

environment Be able to be left in place for up

to seven days to lessen traumatic impact of dressing changes

Have waterproof properties and allow the patient to shower

Incorporate some flexibility and allow movement to deal with any postoperative oedema and to prevent blistering (Roberts et al, 2011).

Oldfield and Burton (2009) suggest that a semipermeable island film or hydrocolloid dressing would be suitable immediately postoperatively, as long as no infection or wound dehiscence has occurred. Ideally, dressings should be left in place for up to 48 hours if no erythema or oozing develops. However, patients might prefer their wounds to be covered for longer, until sutures or clips are removed to prevent them ‘catching’ or ‘pulling’ on clothing (Oldfield and Burton, 2009).

Should complications such as dehiscence or infection occur, it may be helpful for the community nurse to use the principles of a wound-healing framework such as TIME (see Table 3), which is designed to help clinicians systematically interpret the characteristics of a wound and decide on the best intervention. TIME will assist community nurses in their treatment decisions and help to establish wound care goals, particularly around dressing selection.

As well as patient-centred considerations such as pain, comfort and effectiveness, for the community nurse the main considerations for dressing selection include cost-effectiveness, appropriateness, i.e. does the dressing promote wound bed preparation, and whether the product is available on the local formulary.

CONCLUSION

A large proportion of postoperative wound care is managed in the community and while most surgical wounds will progress without complications, it is essential that community nurses have adequate knowledge of potential postoperative complications and how to manage them.

Successful wound management involves a thorough assessment of patient-related characteristics, wound-related features, and identification of potential risk factors, as well as optimising the patient’s environment to better facilitate wound healing. JCN

KEY POINTS Many community nurses will

have to attend patients that have a surgical wound.

The desired clinical outcome for any surgical wound will be to achieve closure and skin integrity with an acceptable cosmetic result, and to avoid any complications.

Patients presenting to community nurses after discharge from hospital may well have experienced postoperative complications or may be at risk of complications following suture removal.

Pain should be assessed using locally available pain assessment tools, such as a visual analogue scale (VAS).

Most surgical wounds will progress without complications, but it is essential that community nurses know about potential postoperative complications and how to manage them.

Successful wound management involves a thorough assessment of patient-related characteristics, wound-related features and potential risk factors.

Other potential factors to consider are the increased financial burden and inverse impact on patients’ quality of life.

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| |T +44 (0)1565 654920 | E info@crawfordpharma.com | W kerramaxcare.co.uk

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24 JCN 2016, Vol 30, No 5

WOUND CARE

REFERENCES

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(2003) Postoperative pain experienced

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Bryant R, Nix D (2012) Acute and Chronic

Wounds: current management concepts.

Elsevier Mosby, Oxford

Dowsett C, Ayello E (2004) TIME principles

of chronic wound bed preparation and

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Drew P, Posnett J, Rusling L (2007) The cost

of wound care for a local population in

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Enoch S, Leaper D (2005) Basic science of

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Franz MG, Steed DL, Robson MC (2007)

Optimising healing of the acute wound by

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Franz M, Robson M, Steed D, et al (2008)

Guidelines to aid healing of acute wounds

by decreasing impediments of healing.

Wound Repair Regen 16: 723–48

Hart J (2002) Inflammation: its role in

the healing of acute wounds. J

Wound Care 11(6): 205–9

Hawker GA, Mian S, Kendzerska T, French

M (2011) Measures of adult pain: visual

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rating scale for pain (NRS Pain), McGill

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McGill pain questionnaire (SF-MPQ),

chronic pain grade scale (CPGS), short

form-36 bodily pain scale (SF-36 BPS),

and measure of intermittent and constant

osteoarthritis pain (ICOAP). Arthritis Care

Res 63(11 Suppl): 240–52

NHS Confederation (2016) Key Statistics on the

NHS. Available online: www.nhsconfed.

org/resources/key-statistics-on-the-nhs

(accessed 29 September, 2016)

NICE (2008) Surgical site infections:

prevention and treatment. Available

online: www.nice.org.uk (accessed 29

September, 2016)

Oldfield A, Burton F (2009) Surgical wounds:

why do they dehisce? Wound Essentials

4: 84–91

Ousey K, Stephenson J, Barrett S, King B,

Morton N, Fenwick K, Carr C (2013)

Wound care in five English NHS Trusts:

result of a survey. Wounds UK 9(4): 20–8

Public Health England (2012) Health

protection report. Volume 7; numbers

50-51. Available online: http://webarchive.

nationalarchives.gov.uk (accessed 29

September, 2016)

Quain A, Khardori (2015) Nutrition in wound

care management: a comprehensive

overview. Wounds 27(12): 327–35

Roberts N, Sorrell N, Biebly A, Searle A (2011)

A survey of postoperative wound dressing

practice before and after implementing

national guidelines. Wounds UK 7(4): 12–21

Vuolo J (2009) Wound Care Made Incredibly

Easy. Lippincott Williams and Wilkins,

London

Wang A, Armstrong E, Armstrong A (2013)

Corticosteroids and wound healing:

clinical considerations in the perioperative

period. Am J Surg 206(3): 2–7

Wu T (2006) Plastic surgery made easy. Simple

dressing techniques for closing skin

defects and improving cosmetic results.

Aust Fam Phys 35: 492

WUWHS (2008) Principles of Best Practice:

wound infection in clinical practice. An

international consensus. MEP, London

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