2 Nursing care in surgery Martina Lepiešová 2.1 Medical and surgical asepsis All health care professionals’ efforts to minimize the onset and spread of infection are based upon asepsis and the principles of aseptic technique. An aseptic environment excludes the presence of any pathogenic (disease-producing) microorganisms and acknowledges only the minimum amount of non-pathogenic microorganisms in the air. The two types of aseptic technique are medical asepsis (clean technique) and surgical asepsis (sterile technique). The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis. Surgical asepsis has to be practiced and maintained not only in operating rooms, delivery areas, burns units or major diagnostic or special procedure areas but fundamentally also during the performance of many procedures in general care areas at the patient’s bedside (e.g. procedures requiring intentional perforation of a patient’s skin such as insertion of i.v. catheter; procedures involving insertion of devices or surgical instruments into normally sterile body cavities such as performing urinary catheterization or when skin integrity is broken due to a surgical incision or burns). In such situations not all the sterile techniques are required as in operation rooms, however the medical aseptic practices have to be applied and the principles of surgical asepsis have to be followed. Examples of medical aseptic practices to break the chain of infection are listed in table 2.1 and the basic principles of surgical asepsis and practices related to each principle are introduced in table 2.2. Purpose - to minimize the number of risk factors (particularly external factors)

predisposing a patient to an infectious process by following the principles of medical and surgical asepsis,

- to remove transient and potentially reduce resident flora of the hands by performing the proper hand washing technique in relation to the procedures being undertaken,

- to conduct all procedures appropriately from the perspective of infection prevention,

- to establish a sterile field prior to all invasive surgical procedures.

Collaborative level - interdependent All health care professionals, even students, are responsible for maintaining medical and surgical asepsis and following their principles in direct or indirect contact with patients with the aim of not contributing to the onset and spread of infections (hospital acquired infections / cross infections / nosocomial infections). Expected patient outcomes - the risk of onset and spread of infection will be minimized by means of

maintaining medical and surgical asepsis and following their principles by all health care professionals, including students,

- the sterility of supplies and articles (as needed specifically to for concrete invasive surgical procedure) will be ensured in the process of preparing and maintaining a sterile field,

- patient is not exposed to microorganisms, - patient will not develop signs or symptoms of infection after procedure, - patient will manifest no signs of infection. Definitions of key terms Infection: Infection is invasion by and multiplication of microorganisms in or on body tissue that have the potential of causing disease; usually results in an immune response. Sepsis: Sepsis is referred to as pathologic state resulting from microorganisms and their byproducts in the bloodstream; an overwhelming inflammatory and coagulation response can rapidly lead to organ dysfunction and death. Asepsis (aseptic technique): Asepsis is defined as the absence of pathogenic microorganisms; the fundamental methods of asepsis are considered to be the methods of disinfection and sterilization (physical and chemical methods or their combination); the aseptic technique must always be performed and followed within all procedures and all the care provided by health care professionals. Medical asepsis: Medical asepsis includes procedures used to reduce the number of and prevent the spread of microorganisms (e.g. hand hygiene, barrier techniques, routine environmental cleaning). Surgical asepsis: Surgical asepsis includes procedures used to eliminate all microorganisms from an area; is represented by the set of measures

preventing pathogenic microorganisms or their spores from entering or being transferred to open wounds or exposed body cavities – these measures prevent contamination of a sterile area by usage of sterile equipment and supplies. Antisepsis (antiseptic technique): Antisepsis is the set of measures to destroy pathogenic microorganisms mainly in the human body’s superficial areas or in its cavities, whereas the microorganisms have already entered the wound or body cavity or such possibility is suspected and the spread of infection has to be avoided; the examples of fundamental methods of antisepsis are e.g. cleaning the wound by antiseptic solutions, irrigating the body cavity by antibiotics. Table 2.1 Medical aseptic practices to break the chain of infection Element of infection chain

Medical aseptic practices

infectious agent or pathogen (disease-producing)

cleanse contaminated objects; perform cleaning, disinfection and sterilization

reservoir or source of pathogen growth

control sources of body fluids and drainage; perform hand hygiene; bathe patients with soap and water; change soiled dressings, dispose of soiled tissues, dressings, linen in moisture-resistant bags; place used syringes and needles in puncture-proof containers; keep table surfaces clean and dry, bottled solutions tightly capped (not opened for prolonged periods); keep surgical wound drainage tubes and collection bags/bottles patent, empty and dispose of them according to institutional policy

portal of exit from reservoir

if respiratory – avoid talking, coughing, sneezing directly over wound or sterile dressing field; cover nose and mouth, wear masks if suffering respiratory tract infections; if urine, faeces, emesis, blood – wear disposable gloves when handling body fluids and substances; wear gown and eyewear if there is a risk of splashing fluids; handle all specimens as infectious

mode of transmission / spread

perform hand hygiene; use personal set of care items for each patient; avoid shaking bed linen / clothes; avoid contact of soiled item with the uniform; discard any item that has touched the floor

portal of entry to the host

if skin and mucosa – keep intact, lubricate skin, offer frequent hygiene, turn position; cover wounds as needed, clean wound sites thoroughly; dispose of used needles as needed if urinary – keep all drainage systems closed and intact, maintain downward flow

host (e.g. susceptible patient)

reduce susceptibility to infection – provide adequate nutrition; ensure adequate rest; promote body defences against infection; provide immunization

Table 2.2 Principles and practices of surgical asepsis Principles Practices all the objects used in sterile field must be sterile

appropriate sterilization process; storage for only a prescribed time – after that unsterile (storage areas clean, dry, off the floor, away from sinks); check the packages of sterile materials (intactness, dryness, expiration date, chemical indicators) – if open, thorny, punctured or wet – consider it unsterile

sterile objects become unsterile when touched by unsterile objects

use sterile handling forceps / sterile gloved hands; if contact with unsterile objects – discard or re-sterilize the objects; if questionable sterility – assume it unsterile

sterile items out of vision or below the waist level are considered unsterile

keep in view – never leave the sterile field out of control, never turn your back on sterile field; keep sterile gloved hands in view, above the waist and below neckline; consider sterile draped tables to be sterile only at surface level

sterile objects can become unsterile by prolonged exposure to airborne microorganisms

keep the doors closed, traffic to a minimum; frequent damp cleaning of the area with detergent germicides; hairs clean, short or enclosed to the net / surgical cap; refrain from coughing / sneezing over a sterile field, keep talking to minimum and wear masks covering the mouth and nose; if mild upper respiratory tract infections – wear masks or refrain from carrying out the procedure; refrain from reaching over a sterile field unless sterile gloved hands; refrain from moving unsterile objects over sterile field

fluids flow in the direction of gravity

always hold wet forceps with the tips below the handles; hold the hands higher than elbows during a surgical hand wash

moisture passing through sterile object draws microorganisms from unsterile surfaces by capillary action

use sterile moisture-proof barriers (special barrier drapes) beneath sterile objects; avoid dampening sterile field and sterile clothes; replace sterile drapes if moist

the edges of sterile field are considered unsterile

2,5 cm margin at each edge of an opened drape is considered unsterile; place all objects inside the edges of sterile field

the skin cannot be sterilized and is considered unsterile

wash the hands prior to procedure, wear sterile gloves / use sterile forceps to handle sterile objects

Related procedures - hand washing procedure, - establishing and maintaining a sterile field, - donning and removing sterile gloves. 2.1.1 Hand washing procedure

The single most important, quite simple and cheap procedure to prevent and control transmission of infection is hand hygiene including hand washing and hand care. The fact is that contact cross infections (hospital acquired infections) are considered to be one of the highest prevalence and hands of health care professionals represent the main risk factor in such a case. Hands contribute to almost every transfer of potential pathogens from one patient to another, from a contaminated object to the patient or from a staff member to the patient. With an increased workload, frequent interruptions in providing care and sometimes limited access to sinks, hand-washing compliance of health care professionals can be a problem. But we have to realize that as hand washing is a crucial responsibility for all health care professionals, it cannot be optional. Microorganisms found on the skin of hands include two categories: - Resident microorganisms (normal hand flora) – are usually deep seated

in the epidermis, are not readily removed and do not readily cause infections. However during surgery or invasive procedures they may enter deep tissues and establish an infection.

- Transient microorganisms – are not part of normal flora and represent recent contamination that usually survives for a limited period of time. They are easily removed by a good hand washing technique. They include most of the organisms responsible for cross infection e.g. Gram-negative bacteria (E.coli, Klebsiella, Pseudomonas spp, Salmonella spp.), Staph aureus, MRSA and viruses e.g. rotaviruses.

Hand washing is a general term used to describe routine hand washing, antiseptic hand rub or surgical hand asepsis. Thus we distinguish 3 recommended levels of hand washing to ensure its suitable performance for the tasks being undertaken: 1. Routine hand washing (hand wash / antiseptic hand wash) – is

performed by washing the hands with soap (better not a plain soap or common cosmetic one, but liquid, pH neutral, disinfecting soap or antiseptic / antimicrobial detergent in a dispenser) and warm water with the aim to remove dirt and organic material, dead skin or most transient microorganisms to make the hands visibly clean. Examples of its use in healthcare practice are e.g. before coming on duty, before preparing food, eating or smoking, before and after performing any bodily functions (e.g. using the toilet, blowing the nose), before and after any significant direct or indirect contact with the patient (e.g. physical

examination), before and after routine use of gloves or other personal protective equipment, after completing the shift, etc.

2. Antiseptic hand disinfection (hygienic hand disinfection / alcohol hand rub / antiseptic hand rub) – is generally carried out with an antiseptic hand rub agent / liquid alcohol agent before any aseptic procedure on the wards and in the areas of isolation with the aim to remove and kill most transient microorganisms. Examples of its use are: before and after performance of any invasive procedure, wound care, urinary catheterisation, insertion of intravenous catheters, etc. (i.e. in all situations where contact with blood, body fluids or substances is possible or where microbial contamination is likely to occur).

Note: In all the situations mentioned if hands are not visibly soiled, use only an alcohol based rub. If hands are visibly dirty or contaminated, they should be washed first with soap and water [alcohol-based products have been found to be more effective than plain soaps or antiseptic soaps; moreover those containing emollients have caused substantially less skin irritation and dryness than plain soaps or antimicrobial soaps tested]. Proper hand hygiene (hand washing and hand rub procedures) together with the basic principles of hand care are introduced in table 2.3 and in figure 2.1. Table 2.3 Hand hygiene – hand care and hand washing procedure Hand care – checklist Sequence of hand washing procedure (hand

washing / hand rub - keep the nails short, don’t wear

nail polish (even a transparent one) or artificial nails

- don’t wear ridged / stoned rings (wedding ring is questionable – refer to the institutional policy)

- remove wrist watches and all jewellery

- roll up / remove long sleeved clothes

- maintain skin intact as far as

possible - cover cuts and abrasions with an

impermeable waterproof plaster - don’t use communal pots of hand

- wet the hands and wrists under running warm water

- take a dose of soap / hand wash into a cupped hand – always operate the dispenser’s application with the elbow to push the detergent

- wash hands for 40 – 60 seconds thoroughly on all the surfaces of hands by six basic movements (Figure 2.1) without adding more water

- keep hands and forearms lower than elbows during washing to facilitate removal of microorganisms

- rinse hands and wrists thoroughly under running water, keeping hands down and elbow up

cream (better individual-use hand creams, creams produced specifically for use after a concrete antiseptic alcohol agent)

- always wear disposable gloves when handling blood, body fluids or substances (but never regard gloves to be a substitute for hand washing!)

- don’t turn the taps off with clean hands – if elbow or foot control isn’t available, use a paper towel to touch and operate the taps

- dry the hands properly with a disposable paper towel or a fresh portion of a roller towel (no need to use several sheets of disposable paper)

- rub the dose of liquid alcohol agent / antiseptic hand rub agent (3 ml by one push) into the skin of dry hands following all six basic movements for at least 30 seconds

Note: An alternative method of hand disinfection as already described is the use of alcohol gels. They are formulated for use without water and are particularly useful in areas where a hand-washing basin is not readily available, or when return to a hand-washing basin is impractical e.g. during a ward round, in between bed making, during a dressing procedure, etc.

Figure 2.1 Six basic movements of hand washing technique to be applied to all hand surfaces

1. Palm to palm 2. Right palm over left

dorsum and left palm over right dorsum

3. Palm to palm, fingers interlaced

4. Backs of fingers to opposing palms with fingers interlocked

5. Rotational rubbing of right thumb clasped in left palm and vice versa

6. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

3. Surgical hand hygiene (surgical disinfection, surgical hand antisepsis, surgical scrub) – is an antiseptic hand wash and antiseptic hand rub performed prior to all invasive surgical procedures, to remove debris, eliminate transient microorganisms and substantially reduce resident hand

flora of the surgical team for the duration of the operation. The agents used must be of a broad spectrum of antimicrobial activity, act rapidly and persist on the skin for several hours. In surgical disinfection the hands should be washed thoroughly up to the forearms (soft and sterile nailbrushes are used only if visibly dirty fingernails, otherwise brushless technique is recommended), rinsed carefully keeping the hands above the elbows and after drying with sterile towels exposed to rubbing the antimicrobial skin agent (usually containing 50% to 90% alcohol combined with chlorhexidine gluconate or detergent-based povidone – iodine solution) into the skin of dry hands, wrists and forearms for 2 x 2,5 minutes (i.e. 2 x 5 ml of agent).

Generally the efficacy of hand washing depends on the application of an adequate volume of a suitable agent with a good technique covering all surfaces of the hands at the right time for the correct duration of time, proper drying of the hands already washed and finally ensuring non-touch technique (particularly in surgical disinfection). 2.1.2 Establishing and maintaining a sterile field Sterile field is a microorganism-free area (including free of spores) established by nurses prior to all invasive surgical procedures (sterile aseptic procedures, operating room procedures) using a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. Sterile drapes establish a sterile field around a treatment site, e.g. a surgical incision, venipuncture site, site for introduction of urinary catheter. Once the field is established, sterile supplies (instruments, dressing materials, antiseptic solutions, etc.) can be placed on it. Equipment - waist-high table, - package containing a sterile drape (or sterile kit to be used as a sterile

field), - sterile equipment and supplies as needed specifically for the procedure

(e.g. sterile surgical instruments – plain dissecting forceps / plain thumb forceps / tissue forceps / pincette, surgical scissors, surgical spoons, haemostat / artery forceps / forceps / pean, suture forceps, scalpels, suture material, sterile dressing material, antiseptic solutions, etc.),

- disposable cap and mask (and/or protective eyewear), sterile gloves, sterile gown.

Assessment 1. Verify that the procedure requires a surgical aseptic technique. 2. Anticipate the number and variety of supplies needed for the procedure

[failure to have necessary supplies causes you to leave a sterile field, increasing the risk of contamination].

3. Assess patient’s comfort, oxygen requirements and elimination needs before preparing the procedure [certain procedures may last a long time].

4. Confirm the sterility of packages - ensure that package is clean, dry, intact (no punctures, tears or

discolouration), check for sterilization expiration dates, sterilization indicator [if moist, or there are any indications it has been previously opened, consider it contaminated and discard it].

Implementation 5. Complete all other priority tasks before beginning the procedure [sterile

field should be prepared as close as possible to the time of its use]. 6. Position patient comfortably for a specific procedure with the help of

assistive personnel. 7. Explain the procedure to the patient (purpose, process, importance of

sterile technique) [enables patient to cooperate and eliminates need to talk during procedure, increasing risk of contamination].

8. Apply cap, mask, and/or protective eyewear and/or gown as needed due to institutional policy.

9. Perform hand hygiene thoroughly (hand washing and alcohol hand rub). 10. Open the package. 10a) To open a wrapped package: - place the package in the centre of work area (clean, dry, flat work surface

above waist level) so that the top flap of the wrapper opens away from you [position like this prevents reaching over the exposed sterile content],

- by reaching around the package (not over!), pinch the first flap on the outside of the wrapper between the thumb and index finger and open the flap [touching the outside of the wrapper maintains the sterility of the inside],

- do the same with side flaps, using the right hand for right flap and vice versa [using both hands avoids reaching over the sterile contents],

- pull the fourth flap toward you, make sure not to touch the uniform by the flap.

Note: To open a wrapped package while holding it, hold the package in one hand (non-dominant) with the top flap of the wrapper opening away from you and by using the other, dominant hand, open the package pulling the corners of the flaps. 10b) To open commercially prepared packages: - if the package has an unsealed corner, hold the package in one hand and

open it by pulling the flap back with the other hand, - if the package has a partially sealed edge, grasp both sides of the edge,

one with each hand, and gently open by pulling apart. 11. Establish a sterile field by using a drape - open the package containing the drape, apply sterile gloves (this is

optional according to institutional policy), with dominant hand pluck the corner of the drape that is folded back on the top and lift the drape out from the cover allowing it to open freely without touching any objects,

- with the other hand, pick up another corner of the drape, holding it well away from yourself,

- lay the drape on a clean and dry surface, placing the freely hanging bottom half farthest from you and then place top half of drape on work surface [to prevent leaning over the sterile field and contaminating it].

12. Add necessary sterile supplies - open the package of the supply while holding outside wrapper in non-

dominant hand, - secure wrapper edges by peeling the wrapper over non-dominant hand, - hold the package approx. 15 cm above the field and allow the contents to

drop onto the field (in bigger packages with bigger supplies, gently place the sterile supply from opened package on the sterile field by approaching from an angle – never reach arms over sterile field).

13. Pour sterile solutions - remove seal and cup from bottle in upward motion, gently pour solution to

the sterile container (metal / plastic / porcelain bowl or cup) with the solution bottle held away from sterile field and the bottle lip approx. 10 – 15 cm above the container.

14. Use sterile forceps (handling forceps / transfer forceps) to handle certain sterile supplies, e.g. to move sterile article from one place to another

- keep the tips of wet forceps (if stored in wet method or made wet during its use) lower than the handles at all times unless sterile gloved hands

[prevention of flowing the liquids from the tips to the handles and later back to tips – handles are unsterile if held by the hands],

- hold sterile forceps always above waist level, within sight, - when using forceps to lift sterile supplies out of the package, be sure they

don’t touch the edges or outside of the wrapper, - don’t permit moist forceps to touch the sterile field if the surface under

sterile field is unsterile and moisture-proof drape is not used as a barrier. Complications - any break in sterile technique (e.g. sterile field has come into contact with

contaminated object, liquids splash onto drape) may lead to contamination of sterile field thus requiring setting up a new sterile field.

Documentation - no recording or reporting is required for this set of skills, - record sterile procedure performed including assessment of patient’s

status prior to and its evaluation during and after the procedure. 2.1.3 Donning and removing sterile gloves Gloves together with the other personal protective equipment (PPE) such as gowns, aprons, eye or facial protectors (glasses, goggles, facial shields), caps and masks, provide a barrier between the source of infection and the host. Gloves help prevent transmission of pathogens by direct or indirect contact. Their use doesn’t negate the need for safe working practices or hand washing – the gloves should be used as an addition to hand washing. There are 3 types of gloves (mostly latex, i.e. natural rubber gloves) worn in health care facilities according to the tasks being undertaken: 1. General-purpose utility gloves – used for manual decontamination of

instruments or equipment used, cleaning and cleansing the areas. 2. Disposable gloves (non-sterile examination gloves) – used when

contamination of hands is anticipated or whenever there is a risk of direct or indirect contact with blood, body fluids and body substances, mucous membranes or non-intact skin (e.g. specimen collection), except the performance of sterile procedures, or procedures involving normally sterile body cavities.

3. Sterile gloves – used for all invasive surgical procedures (sterile procedures, involving normally sterile body areas), e.g. inserting urinary catheters, changing dressings on central i.v. catheters, cleaning open

wounds. Sterile gloves may be donned by the open method (used outside the operating room) and closed method (requires nurse to wear a sterile gown).

Equipment - package of proper-size sterile gloves, latex or synthetic latex-free [gloves

shouldn’t stretch so tightly over the fingers that they can easily tear, yet they should be tight enough to handle objects; in relation to allergy to latex in many health care professionals as well as many patients (with mild to severe reactions to latex) there should be the possibility to choose synthetic non-latex gloves note: hypoallergenic, low-powder or low protein latex gloves still contain latex protein].

Assessment 1. Verify that the procedure requires the use of sterile gloves – consult

institutional policy, consider patient’s risk of infection. 2. Assess patient for the risk factors of he or she being predisposed to latex

allergy reaction (history of asthma, contact dermatitis, rhinitis, food allergies, previous adverse reactions during surgery or dental procedure, previous reaction to latex products – adhesive tape, face mask, bandage, elastic underwear, i.v. tubing, condom, rubber gloves, ostomy bag, etc.) – choose the correct material.

3. Confirm the sterility of the package. Implementation 4. Perform hand hygiene thoroughly (hand washing and alcohol hand rub). 5. Donning sterile gloves (Figure 2.2) - remove the inner glove package from the outer package, place the inner

package of gloves on a clean, dry, flat surface at waist level, - open inner package by plucking the flaps and folded tabs so that the

fingers do not touch the inner surfaces, - identify right and left glove (each having a cuff approx. 5 cm wide), - non dominant hand first: with thumb and first two fingers of your non-

dominant hand, grasp the glove for the dominant hand by the edge of glove cuff touching only the inside of cuff [inner surface of cuff will lie against skin and thus is not sterile], insert the dominant hand into the glove and carefully pull the glove on while keeping the thumb of inserted

hand against the palm [thus the thumb is less likely to contaminate the outside of the glove] leaving cuff and being sure cuff doesn’t roll up wrist,

- with gloved dominant hand pick up the other glove, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm [prevention of accidental contamination of the glove by the bare hand] and pull on the second glove carefully keeping the thumb of dominant hand as far as possible from the palm (abducted back),

- after second glove on, adjust each glove so that it fits smoothly e.g. by interlocking the hands together above the waist level (the cuffs usually fall down – if not, carefully pull cuffs up by sliding the fingers under the cuffs touching only sterile sides).

Figure 2.2 Sequence of donning sterile gloves

6. Removing used gloves - remove them by turning them inside out and discard, - perform hand hygiene thoroughly (hand washing to remove the powder

from hands and alcohol hand rub). Complications - any break in sterile technique (e.g. contamination of glove during its

donning by the bare hand, contamination of sterile gloved hands by touching contaminated or even clean objects, by incorrect position of sterile gloved hands – e.g. below waist level, by developing a tear in a sterile glove) requires application of new sterile gloves immediately.

Documentation - no recording or reporting is required for application of gloves; record and

report possible latex allergy reaction – patient’s response, vital signs, treatment applied and reaction to it,

- record sterile procedure performed including assessment of patient’s status prior to and its evaluation during and after the procedure.

Test your knowledge 1. What is the difference between medical and surgical asepsis? 2. Summarize the principles and rule of hand care except hand washing. 3. When to use different types of hand washing? 4. What is the time exposure to antiseptic hand rub agent in hygienic hand

disinfection and in surgical hand disinfection? 5. Name 3 examples of principles of surgical asepsis and practices for each

principle. 6. Describe and explain how to hold wet sterile handling forceps during

establishing a sterile field while adding necessary sterile supplies. 7. Name risk factors predisposing the patient to latex allergy reaction. Extras for further study - surgical dressing cart (dressing trolley), - surgical instruments, - operation tract, - minor surgical procedures. 2.2 Wound care To manage acute and chronic wounds as a major component of nursing care in surgery it is crucial for nurses to understand the physiology of wound healing, factors affecting it and specific measures to promote it. Purpose - to identify types of wounds and appropriate treatment options for certain

types, - to assess and report all the characteristics of a wound properly including

wound healing process, - to promote wound healing and minimize the risk of complications, - to perform specific procedures of wound care correctly (e.g. removing

soiled dressing, wound cleansing (cleaning, irrigation), applying a sterile dressing, suture removal, care of a wound-drainage system),

- to prevent infection. Collaborative level

- interdependent Nurses usually assist the physicians in wound management (wound scrubbing, suture removal and removal of a drain should be performed only by the surgeons). An initial surgical wound dressing is usually not removed until a physician decides to remove it and inspects the wound. In the case of a regular need to cleanse the wound or change its dressing (e.g. if excessive amount of drainage occurs), nurses perform these procedures themselves. The nurse’s responsibility is to assess and document wound characteristics. Moreover, nurses are responsible for patient education particularly concerning chronic wound management. Expected patient outcomes - patient will display normal wound healing / stabilization if healing isn’t

possible (wound is clean, free of drainage and inflammation / drainage is decreased in amount and type, skin integrity is maintained),

- patient is not exposed to microorganisms / will not develop signs of surgical wound infection.

Definitions of key terms Wound: Wound is defined as any break in the continuity of the skin, mucous membranes, bone or any body organ; there are different types of wounds, e.g. intentional wounds (occurring during therapy such as incisions, venipunctures, radiation burns) or unintentional (accidental); other types are open wounds (when the skin or mucous membrane is broken) or closed (if tissues are traumatized without a break in the skin). Some examples of wound types and their characteristics based on different classifications are listed in table 2.4. Healing (regeneration): Healing is a quality of living tissue involving 3 phases (Table 2.5). There are 3 types of healing distinguished by the amount of tissue loss – primary, secondary and tertiary intention healing (Table 2.6). Complications of wound healing are e.g. haemorrhage (persistent bleeding), infection, keloid formation (excessive amount of connective tissue in the scar surface in secondary intention healing wounds), dehiscence (partial or total rupturing of a wound due to absence of the “healing ridge”) with possible evisceration (protrusion of the internal viscera through an incision). Table 2.4 Wound classification Type Description and characteristics

according to cause – how wounds are acquired incision sharp instrument (scalpel, knife) – open, painful wound contusion blunt instrument – bruised skin, closed wound abrasion falls / intentional to remove pockmarks – surface scrape puncture sharp instrument – penetration of skin and underlying tissues laceration accidents (machinery) – tissues torn apart, edges jagged penetrating wound

accidents (bullet, metal fragments) – penetration of skin and underlying tissues

according to likelihood and degree of contamination clean surgical, uninfected, not entering the respiratory, alimentary, genital

or urinary tracts (primary closed wounds, sutured by primary suture or drained with closed drainage)

clean-contaminated

surgical, entering the respiratory, alimentary, genital or urinary tracts, but no evidence of infection

contaminated fresh, open, accidental or surgical with the evidence of inflammation dirty old, accidental wounds containing dead tissue, wounds with

evidence of clinical infection (purulent drainage etc.) according to depth (the tissue layers involved in the wound)

partial-thickness

confined to the skin (dermis and epidermis); healed by regeneration

full-thickness involving dermis, epidermis, subcutaneous tissue and possibly muscle and bone; require connective tissue repair

according to course and duration of wounds acute developed in healthy tissue, e.g. surgical wounds, abrasions,

incisions, 1st and 2nd degree burns chronic developed in tissue that is trophically impaired / are acquired by

secondary dehiscence, e.g. ulcers (venous, arterial, diabetic, pressure ulcers, malign wounds, radiation burns), 3rd degree burns

classification of open / secondary intention healing wounds according to the colour of wound by WCS (Woundcare Consultant Society); Marion

Laboratories, Inc. red (or pink) clean, granulating (new healthy tissue) and epithelializing wound,

healing well red or pink granulation tissue the goal of wound management is to protect red wounds and cover them by selection of transparent film or hydrocolloid dressing maintaining clean and slightly moist wound environment and minimize damage to healing tissue (i.e. gentle cleansing, avoiding use of dry gauze or wet-to-dry saline dressings, changing the dressing as infrequently as possible)

yellow wound coated by dead subcutaneous fat tissue, liquid or semi-liquid slough (grey necrotic slough) often accompanied by purulent drainage the goal of wound management is to cleanse yellow wounds (to absorb drainage and remove non-viable tissue) by selection of moisture-retentive dressings enhancing debridement (wet-to-wet or wet-to-dry dressing, impregnated non-adherent dressings, hydrocolloids, hydrogels, alginates, other exudates absorbers), wound irrigations

black covered with black eschar (representing full-thickness tissue

destruction) – a thick leathery necrotic devitalized tissue with no proper circulation thus providing excellent medium for bacterial growth require debridement (removal of infected and necrotic material) the goal of wound management is to debride black wounds by chemical enzymes (autolytic debridement with the use of occlusive or semiocclusive dressings), mechanical debridement (surgical necrectomy)

Table 2.5 Phases of wound healing Inflammatory phase

essential for healing, initiated immediately after injury, lasts 3-4 days haemostasis (the cessation of bleeding by means of vasoconstriction of large blood vessels in the affected area, retraction of injured vessels, deposition of fibrin and formation of blood clots) – scab is formed on the wound surface, a thin wall of epithelial cells develops across the wound inflammatory response – increased blood supply to the wound to bring substances and nutrient needed in healing process – localised redness and oedema cellular responses – cell migration (leukocytes – neutrophils, macrophages) – phagocytosis, angiogenesis factor (AGF) secretion

Proliferative phase

extends from day 3-4 to about day 21 after injury synthesis of collagen (whitish protein substance adding strength to the wound) – raised “healing ridge” appears under the intact suture line (can be felt along a healing wound) development of granulation tissue – translucent red colour, fragile tissue, risky for bleeding epithelialization – epithelial cells migrate to matured granulation tissue proliferating over this connective tissue base to fill the wound – pink scar

Maturation (remodelling) phase

from day 21 to 1-2 years after injury continue in the synthesis of collagen – scar becomes a thin, less elastic, white line

Table 2.6 Types of healing Primary intention healing (first intention healing, per primam intentionem)

e.g. in clean surgical incisions in which wound edges were pulled together with sutures, staples or adhesive tapes; means the tissue surfaces have been approximated, closed and there is minimal or no tissue loss (minimal granulation tissue and scaring occurs); healing occurs by connective tissue deposition

Secondary intention healing (per secundam intentionem)

e.g. in open extensive wounds with considerable tissue loss (such as pressure ulcers) in which the edges cannot be approximated (there is some gap between edges); in such healing the repair time is longer as granulation tissue gradually fills in the area of the wound with scar tissue, the scaring is greater, the surface closure is thicker and the susceptibility to infection is greater due to the slowness of the process; healing occurs by granulation tissue formation and contraction of wound edges

Tertiary intention healing (delayed or secondary closure, per tertiam intentionem)

indicated when there is a reason to delay suturing a wound (because of poor circulation in the area, or to allow oedema or infection to diminish) to the time after the initial stage of deposition of granulation tissue (usually for 3 to 5 days), e.g. healing in opened abdomen

Related procedures - cleaning a wound, - applying a sterile dressing.

2.2.1 Cleaning a wound and applying a sterile dressing Wound cleansing delivers a fluid or cleansing solution to the wound surface by means of a specific mechanical force and assists with the separation and removal of debris (i.e. foreign material, excess slough, particulate matter, bacteria, necrotic tissue and residue of wound care products). An appropriate cleansing solution does not harm the tissue (physiological solutions are recommended such as isotonic saline or lactated Ringer’s solution; formerly commonly used antimicrobial solutions such as povidone – iodine, 3% hydrogen peroxide, 60% spiritus, 4 % Tanin alcohol have proved to have caustic effects on granulation tissue and the skin after prolonged usage) and is delivered by adequate mechanical cleansing action of scrubbing, soaking or irrigation (the last two are mostly performed in practice). Principles of basic wound cleansing are listed in table 2.7. Table 2.7 Basic principles of wound cleansing - choice of solution is the physician’s

preference - solutions used are always sterile,

warmed to body temperature when possible

- use a sterile technique for surgical wounds and a clean technique for chronic wounds

- cleanse always from “clean to dirty” area (difficult to differentiate) – the suture line or any area being cleansed is considered the “least contaminated” and surrounding skin surfaces are considered “contaminated”

- clean the wound during every dressing change if contaminated or exudate if excessive, otherwise avoid repeated unnecessary cleaning

- prefer irrigating the wounds by a stream of solution against mechanical cleaning

- use a new sterile gauze swab for each stroke while cleaning (do not use cotton wool balls)

- suture line is always cleansed first / the drain site is cleansed using circular strokes (commonly used methods to clean a surgical wound and drain site are in figure 2.3)

- various methods of cleansing the wounds are described – variations include the following (strong need for further research): - holding cleaning swabs with

forceps versus sterile gloved hands - cleaning from wound in outward

direction versus cleaning in any direction unless there are signs of infection

- cleaning the surrounding skin first and then the wound versus cleaning

- maintain wound moisture – avoid drying it after cleaning

the wound first and then the skin - not cleaning the wound at all if it

appears to be clean Figure 2.3 Methods of cleaning surgical wound and a drain site

clean it from top to bottom start at the centre moving toward one end, then start at the centre again and work toward the other end, continue with other movements in straight lines moving away from the suture line

start in the area immediately next to the drain (with each new swab attempt to clean a little further out from the drain)

Wound dressings are applied for the following purposes – to protect the wound from mechanical injury and microbial contamination, to maintain humidity, to absorb drainage and/or debride a wound, to provide thermal isolation, to prevent haemorrhage (if pressure dressing is applied), to immobilize the wound (thus facilitate healing and prevent injury) and to provide psychological / aesthetic comfort. There are different types of dressings – traditional dressing is gauze (the modes of applying gauze dressings are: dry-to-dry, wet-to-dry, wet-to damp and wet-to-wet dressings) and there are new synthetic modern dressings to provide moist wound healing (occlusive / semiocclusive, transparent adhesive films, impregnated nonadherent dressings, hydrocolloids, hydrogels, polyurethane foams, alginates, exudate absorbers, etc.). The layers of dressing are primary layer (contact, under) represented usually by a wet sterile gauze square, secondary layer (absorbent, outer, cover) composed of dry gauze squares, surgipads or cotton wool layer if wound drainage is excessive and fixation layer, performed by e.g. tapes (elastic adhesive tape, nonallergenic tape) or bandages / binders, securing the dressing not to become dislodged. The principles of securing dressings are listed in table 2.8.

Not all surgical dressings require changing – sometimes the dressing remains in place until the sutures are removed; however, most surgical dressings are changed regularly to prevent the growth of microorganisms. Table 2.8 Basic principles of securing the wound dressing - place the tape so that the dressing cannot be folded back (strips of tape at the ends

of dressing and across the middle), ensure the tape is long and wide enough (Figure 2.4)

- place the tape in the opposite direction from the body action (across a joint, not lengthwise)

- place the tape at 90 degree angle to suture line if possible (so that wound edges are pulled together)

- when removing the original adhesive tape, always pull the tape toward the wound to prevent strain on the sutures and to reduce the risk of wound dehiscence (pull the tape gently but firmly while holding down the skin with non-dominant hand to provide counter-traction); if necessary to loosen the tape particularly on hairy surfaces, moist it with some solvent (e.g. acetone)

Figure 2.4 Securing the wound dressing by a tape (correct and incorrect way)

Equipment - disposable / sterile gloves [disposable to protect yourself during removal

of soiled dressing; sterile to examine the depth of a wound / to hold sterile dressing supplies], other PPE – mask, protective eyewear, gown [optional],

- sterile handling forceps in a sterile cylinder / jar [to handle sterile instruments or sterile dressing supplies],

- sterile cassette with sterile surgical instruments (e.g. forceps to hold cleansing swab; probe to assess the wound depth; surgical spoon / scalpel for mechanical debridement / surgical necrectomy; suture forceps to make sutures; surgical scissors to cut the sutures / sterile dressings / to shorten the drains, etc.),

- sterile cleansing solutions and irrigation delivery system if irrigation is to be performed (sterile pink needle, sterile syringe, sterile catheter) [to withdraw solution from a sterile bottle and apply it to/on the wound],

- dressing supplies – sterile gauze swabs, sterile gauze squares in sterile packages (paper wrapper – Lucasteric sac / paper-folic wrapper / bowls / cassettes) or commercially prepared sterile packages of synthetic modern dressings,

- clean bandage scissors [to cut the packages, to cut the bandages], - adhesive tapes / bandages of proper width / binders [to secure the new

dressing], - clean kidney dish / collection basin and disposable waterproof biohazard

bag, - folded paper towels or extra moisture-proof underpad [to protect bed /

patient’s personal clothes / pyjama], - extra bath blanket [to cover patient’s intimate parts when needed], - additional supplies required (e.g. extra absorbent dressings – surgipads,

folded cotton wool, ordered ointments, powders, etc.). Assessment 1. Review physician’s orders concerning wound cleansing / any other wound

care procedure (increased frequency of cleansing, specific supplies required, what to report, etc.).

2. Assess recent recording of any characteristics related to patient’s wound to get prepared for the procedure and to identify the changes in wound condition after removal of soiled dressing (extent of integrity of skin impairment; wound location; wound size in length, width, depth; signs of infection – e.g. elevation of body temperature, wound odour, wound colour; wound drainage as for amount, colour, consistency, type – serous, sanguineous, serosanguineous, purulent; stage of wound healing; wound dressing – if clean, dry, evidence of bleeding, profuse drainage; identify if patient is at risk of wound healing problems).

3. Assess patient’s history of allergies to antiseptic solutions, tapes or dressing materials, assess the risk factors predisposing for latex allergy reaction – modify the selection of supplies to use the correct material.

4. Assess patient’s comfort level or pain (on numeric scale of 0 to 10), symptoms of anxiety, elimination needs before preparing the procedure [discomfort may be related directly to wound, anxiety to anticipation of unknown procedure; certain procedures may last a long time].

5. Confirm the sterility of all packages and sterile supplies. Implementation

6. Explain the procedure to the patient (purpose, process, importance of sterile/clean technique) [to reduce anxiety, to enable patient to cooperate].

7. If necessary, apply premedication (prescribed analgesic) 30 to 45 minutes prior to the procedure [to ensure patient’s comfort positioning, to enable patient to cooperate].

8. Position patient comfortably for specific wound care procedure, expose the wound and place extra towels and kidney dish close to the wound area to protect bedding and collect any possible exiting fluids [to permit gravitational flow of possible excessive drainage or irrigating solution into this collection basin].

9. Close the room door / bed curtains, use extra bath blanket to cover the patient if needed.

10. Prepare a waterproof bag for disposal of soiled dressings within reach, make cuff on it.

11. Perform hand hygiene thoroughly (hand washing and alcohol hand rub). 12. Apply disposable gloves and/or other PPE as needed due to institutional

policy. 13. Remove soiled dressings appropriately - untie binders or bandages / cut them with bandage scissors (but never

directly above the wound) / remove adhesive tapes; remove all the dressing layers always with underside away from patient’s face [not to make him/her upset], taking care not to dislodge any drains while removing the under layer [if gauze sticks to drain, support the drain with one hand while removing the dressing; if dressing material adheres to any tissue during removal, soak it with normal saline],

- assess amount, type and odour of wound drainage based on the soiled dressings,

- discard the soiled dressings including gloves used in waterproof bag. 14. Wash the hands. 15. Assess the characteristics of wound / wound healing [if assessing includes

touching the wound, e.g. examining the depth of wound, put on sterile gloves].

16. Describe the appearance of the wound and indicators of wound healing to the patient.

17. Set up sterile supplies (using surgical aseptic technique) - by using handling forceps draw up the forceps / any other instrument from

the cassette always catching the middle part of an instrument, pass it to the

physician by the handles or carefully put it into sterile jar to be offered later [don’t contaminate the cassette cover or instrument’s tips; close the cassette as soon as possible],

- cut the sterile package of gauze swabs with bandage scissors (usually paper wrapper), open the package carefully [don’t touch the inside of the wrapper], draw the swab by handling forceps and pass it to the physician to be carefully caught by the physician’s forceps [avoid touching the instruments],

- open the sterile cleaning solution and pour it over the sterile swab held by the physician’s forceps to moisten the swab [be aware not to touch the swab keeping the bottle lip approx. 10 cm above the swab; physician should hold the swab approx. 10-15 cm over the kidney dish as well],

- when ordered, prepare the irrigation delivery system by filling the sterile syringe with irrigation solution and/or attaching the sterile catheter,

18. Cleanse the wound by mechanical cleaning or irrigation - if indicated to take a specimen from the wound, always obtain it before

cleansing it, - clean the wound using the forceps and gauze swabs moistened by cleaning

solution following the principles of wound cleansing [keep the forceps tips lower than the handles all the time, use separate swab for each stroke, discard each swab used],

- if a drain is present, clean it after the incision [the main surgical incision is considered cleaner because of considerable drainage around the drain], support and hold the drain erect while cleaning around it,

- if irrigating wound, flush it using slow continuous pressure, ensuring gravitational flow of irrigating solution through the wound into this collection basin,

- dry the surrounding skin with dry gauze swabs as required, if needed clean up the skin from tape marks with some solvent.

19. Apply powders / ointments as ordered - shake powders directly onto a wound / use sterile applicators to apply

ointments [sterile tongue blades / sterile blunt instruments such as forceps, surgical probe]

20. Apply dressings to the drain site and the incision - apply all the layers of dressings as needed [primary layer is usually

applied moistened with cleaning solution, secondary is usually dry or absorbent if needed; manipulate with forceps using surgical aseptic

technique; if necessary, use forceps to feed the gauze square gradually into deep depressed wound areas – undermining, tunneling],

- if a drain is present, place a pre-cut sterile gauze square [or cut the sterile square with sterile surgical scissors] nearly around the drain,

- secure the dressings as needed. 21. Remove PPE, assist the patient into a comfortable position, dispose

of equipment and soiled supplies and perform thoroughly hand hygiene. 22. Inspect the wound dressing periodically to determine patient’s

response to wound care procedure (at least every shift). Complications - wound dressing is dry and too adherent when removed, - appearance of bleeding or serosanguineous drainage, retained fluid or

debris, increased pain or discomfort in the patient, signs of inflammation, - increase of wound drainage (more than dressing can absorb), - irritation of the skin around the wound (red, macerated or excoriated), - suture line opening extends or a drain is removed accidentally, - dressing doesn’t stay in place. Documentation - record the procedure performed (e.g. type of solution used, type and

amount of dressings applied, frequency of dressing change) including wound assessment before and after the procedure, patient’s tolerance of the procedure, patient’s status prior to and its evaluation during and after the procedure,

- immediately report to the physician (if he or she isn’t present) any evidence of fresh bleeding, sharp increase in pain, accidental removal of a drain, evidence of wound dehiscence or evisceration (particularly in the wounds after removal of sutures), signs of shock,

- record and report possible allergy reaction – the cause, patient’s response, vital signs, treatment applied and reaction to it.

Test your knowledge 1. Describe selected types of wounds according to their causes – laceration,

incision, abrasion. 2. Does the classification of wounds according to their colour (e.g. yellow,

red, black) refer to primary intention healing wounds or secondary intention healing wounds?

3. Describe and explain the phases of wound healing. 4. What type of gloves would you wear to remove a soiled wound dressing? 5. Would you use gloves to assess the characteristics of a wound or wound

healing? If yes, when and what type of gloves? 6. How would you cleanse a surgical wound by mechanical cleaning?

Explain procedure, equipment, principles. Extras for further study - factors affecting wound healing, - promotion of normal wound healing, - signs and symptoms of wound infection, - wound assessment, - care for accidental wounds (first aid), - teaching considerations concerning wound care, - drains and drainage systems, - suture removal, - wound V.A.C. (vacuum-assisted closure) system promoting wound

healing. References BERMAN, A. - SNYDER, S. J. - KOZIER, B. - ERB, G. 2008. Kozier and Erb´s Fundamentals of Nursing. Concepts, Process and Practice. 8th ed., New Jersey : Person Education, 2008. 1631 p. ISBN 0-13-171468-6. CRAVEN, R.F. - HIRNLE, C.J. 1992. Fundamentals of Nursing. Human Health and Function. Philadelphia : J.B. Lippincott Company, 1992. 1522 p. ISBN 0-397-54669-6. HLINKOVÁ, E. 2007. Základné ošetrovateľské techniky a postupy v chirurgii. In Osacká, P. a kol. Techniky a postupy v ošetrovateľstve. [CD-ROM]. 1.vyd. Martin : Ústav ošetrovateľstva, JLF UK, 2007. 505s. ISBN 978-80-88866-48-0. KOWALAK, J. P. 2008. Lippincott´s Nursing Procedures. 5th ed., Philadelphia : Lippincott Williams and Wilkins, 2008. 949 pp. ISBN 13: 978-0-7817-8689-8, ISBN 10: 0-7817-8689-4. KOZIER, B. - ERB, G. - BERMAN, A. - SNYDER, S. 2003. Kozier and Erb´s techniques in clinical nursing. Basic to intermediate skills. 5th ed., Upper Saddle River. N.J. : Prentice Hall, 2003. 752 p. ISBN 13: 978-0-13-114229-9. KOZIER, B. - ERB, G. - BERMAN, A. - SNYDER, S. 2004. Fundamentals of Nursing. Concepts, Process and Practice. 7th edition, New Jersey : Pearson Education, 2004. 1518 p. ISBN 0-13-122878-1. KUHN TIMBI, B. 2009. Fundamentals Nursing Skills and Concept. 9th ed., Philadelphia : Lippincott Williams and Wilkins, 2009. ISBN 978-0-7817-7909-8.

McENTYRE, R.L. 1989. Practical Guide to the Care of the Surgical Patient. 3rd ed., St. Louis : The C.V. Mosby Company, 1989. 348 p. ISBN 0-8016-3330-3. Nursing procedures and protocols. 2003. 1st ed., Lippincott Williams & Wilkins. 2003. 672 p. ISBN-13: 978-1582552378. PERRY, A.G. - POTTER, P. A. 2004. Clinical Nursing Skills and Techniques. 6th ed., St. Louis : Mosby Inc., 2006. 1611 p. ISBN-13: 978-0-323-02839-4, ISBN-10: 0-323-02839-X. RICE, R. 1995. Handbook of Home Health Nursing Procedures. 1st ed., St. Louis : Mosby–Year Book, Inc., 1995. 396 p. ISBN 0-8016-6946-4.