• Choose a category
• All
• Classic-Fiction

By Root 1936 0

have demonstrated that it is unnecessary to dress surgical wounds after 48 hours and that this did not cause an increase in infection rates (Meylan and Tschantz 2001, Sticha et al. 1998). Chrintz et al. (1989) also found that early removal of dressings resulted in cost saving, reduced nursing time spent on dressings and increased ability for patient self-care. However, this is largely dictated by patient choice. Patient education and psychological support will be required prior to exposing a wound as it may cause patient distress.

If a dressing is required, a simple shower-proof, non-adherent dressing should be applied. Care should be taken to avoid applying the dressing under tension as this may blister the skin (Gupta et al. 2002). Gauze-based dressings should not be used to dress surgical wounds, as these can completely adhere to the wound and become part of the healing tissue, causing excessive pain, wound damage and excessive use of nursing time on removal (Hollinworth and Collier 2000, Vermeulen et al. 2005).

When a dressing is applied, it should be changed using aseptic technique, as clinically indicated or as per surgical instructions (see Chapter 15). On discharge, the patient should be referred to a community nurse or educated about how to care for themselves, including observing for signs of infection and swelling/seroma formation, in order to continue wound care at home.

Drain sites should remain uncovered unless there is exudate. If exudate is present, a simple non-adherent dressing should be applied around the drain and reviewed as required or at least every 24 hours.

Surgical wound complications

Dehiscence and infection are the two main complications associated with surgical wounds. Dehiscence can range from splitting open of the skin layers to complete dehiscence of the muscle and fascia, exposing internal organs, and occasionally incisional hernia with outer layers intact (Baxter 2003).

Factors associated with surgical dehiscence include infection, age, malnutrition, being male, long-term steroid use, previous radiotherapy, smoking, diabetes and rheumatoid arthritis, which can impair healing by affecting the microcirculation (Poole 1985). Obesity causes increased subcutaneous dead space, rendering the patient more susceptible to haematoma and seroma formation and increased incidence of infection (Armstrong 1998). Tight suturing can tear the skin and affect vascularity of the wound edges, and may result in necrosis and wound breakdown (Westaby 1985).

Occassionally wound manager bags are required to drain the excessive exudate from a partially or fully dehisced wound. They are indicated if wound dressings are unable to manage the discharge from a wound and skin integrity is compromised.

Wound infection is characterized by purulent exudates, redness, tenderness, elevated body temperature and wound odour. A swab, pus sample and blood cultures should be taken to identify the causative micro-organism and appropriate treatment commenced to eradicate it. Factors affecting the incidence of wound infection are similar to those affecting dehiscence, although drains and sutures increase the risk of infection and should be removed if infection is indicated (Gilchrist 1999). However, the signs are also seen in the normal postoperative inflammatory response, lasting up to 48 hours. Persistent inflammation beyond this period or the presence of pus or purulent discharge, or pyrexia of the patient may indicate infection.

As with drains, venous access devices, chest drains and indwelling urinary catheters, wound dressings and clips/sutures can also increase the risk of infection. See Chapter 3. Each should be assessed on a daily basis and/or if infection is apparent to determine if they are still clinically indicated and they should be removed at the earliest opportunity. If infection is apparent, samples from the device and blood cultures should be sent for microbiology and appropriate eradication treatment commenced.

Methods for management of pain

Effective management of pain following surgery requires that information