WOUND CAREAND HEALING IN PERIOPERATIVE PRACTICE...provide wound care in collaboration with a diverse...

WOUND CARE AND HEALINGIN PERIOPERATIVE PRACTICE

1972

1972WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability,negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions,or ideas contained in the material herein. Because of rapid advances in the healthcare sciences in particular, independentverification of diagnoses, medication dosages, and individualized care and treatment should be made. The material containedherein is not intended to be a substitute for the exercise of professional medical or nursing judgment.

The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN,INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDINGBUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRDPARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The followingcredit line must appear on the front page of the photocopied document:

Reprinted with permission from The Association of periOperative Registered Nurses, Inc.

Copyright 2014 “WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE.”

All rights reserved by AORN, Inc. 2170 South Parker Road, Suite 400,

Denver, CO 80231-5711 (800) 755-2676 www.aorn.org

Video produced by Cine-Med, Inc.

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PURPOSE/GOAL .............................................................................................................................4OBJECTIVES....................................................................................................................................4INTRODUCTION.............................................................................................................................5TYPES OF WOUND CLOSURE .....................................................................................................5PHASES OF WOUND HEALING ...................................................................................................6FACTORS AFFECTING WOUND HEALING................................................................................7SURGICAL SITE INFECTIONS .....................................................................................................8

Wound classification................................................................................................................9Categories of SSIs .................................................................................................................10

PERIOPERATIVE WOUND TREATMENTS................................................................................11COMPLEX WOUND CARE ..........................................................................................................15PEDIATRIC WOUND CARE.........................................................................................................15COLLABORATION........................................................................................................................16SUMMARY.....................................................................................................................................16POST-TEST.....................................................................................................................................22POST-TEST ANSWERS.................................................................................................................23

WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE

Wound Care and Healing in Perioperative PracticeTABLE OF CONTENTS

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PURPOSE/GOALThe purpose of this study guide and accompanying video is to educate perioperative registered nurses (RNs) and other interestedhealth care personnel about the physiology of wound healing and to review key concepts and practices for providing woundcare in the perioperative setting.

OBJECTIVESAfter viewing the video and completing the study guide, the learner will be able to:

1. Define wound healing.2. List types of wound closure.3. Describe the physiology of wound healing.4. Describe how wounds are classified.5. Discuss factors that affect wound healing.6. Categorize surgical site infections (SSI).7. Describe practices to prevent SSIs.8. Describe perioperative wound management practices and treatments.


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INTRODUCTIONWounds are caused by surgical incision or excision; by traumasecondary to mechanical, thermal, or chemical destruction oftissue; and by underlying acute or chronic disease processes.1Wound healing can be defined as the body’s process of re-establishing continuity in the tissues by replacing dead andmissing cellular structure and tissue layers with viable tissue.2Wound management is an essential competency area forperioperative RNs who care for patients with a wide range ofwounds every day in both inpatient and ambulatory settings.To optimize wound healing, these patients need treatment thatis tailored to their unique medical and surgical histories andspecific wound characteristics. Patient education also iscrucial for successful wound healing because by necessity,much wound care occurs outside the hospital or ambulatorysurgery facility.

To provide quality wound management, perioperative RNsand other clinical personnel need to fully understand thephysiology of wound healing, risk factors for impaired anddelayed healing, and best practices and current products thatsupport healing. In addition, perioperative RNs should becompetent in classifying and documenting surgical wounds inaccordance with the Centers for Disease Control andPrevention’s (CDC) Surgical Wound Classification system.3

The field of wound management has become increasinglycomplex as emerging research reveals new information aboutwound healing and as new wound care products enter themarket. This study guide and the accompanying video willreview wound care and wound healing based on currentresearch and expert clinical recommendations.

TYPES OF WOUND CLOSUREThere are three main types of wound closure.1

Closure by primary intention. This type of closure occurswhen the clinician creates an operative wound in an asepticenvironment with minimal destruction of tissue and tissue

reaction. The wound also heals under optimal conditions – theskin edges are approximated with skin staples or tape soonafter wounding; there is no tissue loss or dead space; drainageis minimal; and the wound is handled with strict adherence toaseptic technique.

Closure by secondary intention. Typically, this type ofclosure involves chronic wounds, contaminated wounds, andwounds characterized by marked tissue loss.1 The skin edgestypically cannot be approximated, and the wound is left openand allowed to heal from the inside to the outside surface. Thispractice enables cleaning and dressing of the healing wound.The tissue gap gradually fills in with granulation tissue madeup of fibroblasts and capillaries and subsequently contracts toreduce the size of the wound. The healing process takes longerand involves substantially more scar tissue than closure byprimary intention.

Delayed primary closure (tertiary closure). In this type ofclosure, the wound is closed three or more days after injuryor surgery.1 Clinicians may elect delayed primary closure formarkedly contaminated wounds, such as wounds incurred inwar zones, ileostomy closure, and peritonitis, or if a patient ishemodynamically or otherwise unstable.1,4 Delayed primaryclosure typically requires a primary and secondary suture line,such as the use of retention sutures, and clinicians use delayedprimary closure surgery to reduce the risk of surgical site


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infections (SSI). In a meta-analysis of eight randomizedstudies of delayed primary versus primary closure, however,researchers found flaws in design and outcomes assessment.4The researchers concluded that the trials included in the meta-analysis had failed to provide definitive evidence that delayedprimary closure prevents SSI. Additionally, in a Cochranesystematic review, the researchers concluded that there was alack of robust evidence to guide clinical decision-makingregarding when to close traumatic wounds.5 In a retrospectivestudy of fractures, researchers identified a significantly higherrate of deep infections in delayed primary closures (17.8%)compared with primary closure cases (4.1%; P = 0.0001).6The researchers concluded that immediate closure of carefullyselected grade I, II, and IIIa open fractures was safe and wasassociated with a lower infection rate than delayed primaryclosure.

PHASES OF WOUND HEALINGThe physiology of wound healing is highly complex anddynamic, and research continues to reveal new informationabout the cellular, humoral, and molecular processes involved.The literature does not concur on the number or nomenclatureof stages involved in wound healing. For the purposes of thisstudy guide, however, we will define three main phases ofwound healing as: inflammation, proliferation, andremodeling.1

The cellular- and tissue-level events of wound healing oftenoverlap or occur simultaneously. The first and immediatephysiologic response to wounding, however, involves themechanism of hemostasis. Immediately after injury, bloodvessels at the wound site undergo vasoconstriction tominimize blood loss. Platelets activate the intrinsic clotting(or coagulation) pathway, and injured tissue activates theextrinsic clotting pathway.2 Platelets adhere to the damagedendothelium and release adenosine diphosphate (ADP), which

triggers platelet clumping to help fill the wound and slowbleeding. Vasoconstriction is followed by histamine-inducedvasodilation, which enables platelets and other blood cells toenter the wound. Fibrinogen is cleaved into fibrin, which inturn enters the wound to form an initial coagulum, or clot.Thrombocytes (platelets) release growth factors, and chemo-attractants recruit neutrophils and macrophages, which releasecytokines (extracellular signal proteins or peptides) such asinterleukins that help direct and orchestrate the healingprocess. These events induce the first phase of wound healing,the inflammatory phase.1

The inflammatory phase usually lasts one to four days.1During this phase, plasma, neutrophils, and macrophages leakinto the wound, causing the classic signs of inflammation:redness, swelling, heat, and pain. An exudate from the woundmay also be observed. Neutrophils predominate during theearly inflammatory phase, while macrophages predominatelater.2 Macrophages secrete numerous factors that trigger themultiplication of smooth muscle and endothelial cells.

Leukocytes phagocytize bacteria and dead or damaged tissue,helping to clean and debride the wound and prevent infection.

The proliferative (or granulation) phase is characterized by


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the production of granulation tissue, neovascularization, andre-epithelialization.1 During proliferation, granulation tissuecomposed of connective tissue and new capillaries fills thewound gap. Myofibroblasts (connective tissue cells) attach tocollagen and contract, pulling the edges of the wound togetherto reduce scar tissue. Epidermal growth factors induceepithelial cells to migrate from the edges of the wound acrossthe bed of granulation tissue, covering and closing the defectwith a thin tissue layer. This protective barrier helps preventfluid and electrolyte loss and reduces the risk of infection.

The third phase of wound healing is remodeling, whichbegins approximately two to four weeks after the initial woundand may continue for up to one year or longer.1,7 During thisphase, granulation gradually stops and apoptosis(programmed cell death) causes the recession of existinggranulation tissue. Wound contraction continues, and scartissue gradually re-organizes into an avascular, acellularmatrix primarily composed of parallel bundles of collagen.This process improves the tensile strength of the wound,although scar tissue has only about 80% of the strength ofunwounded tissue.7

FACTORS AFFECTING WOUND HEALINGNumerous patient-specific and perioperative risk factorsaffect the rate and outcome of wound healing. Patient-specificrisk factors for delayed wound healing include thefollowing:7,8

• Aging slows the healing process, especially in males,even when they do not have comorbid conditions.

• Decreased oxygen levels decrease oxygen tension tothe wound and compromises its tensile strength.

• Obesity places excess tension on wound edges and isassociated with local hypoperfusion, contaminatedskin folds, and pressure injuries which increase the

potential for complications of the wound healingprocess.

• Psychological stress increases blood glucose levelswhich may negatively affect the healing process.

• Smoking increases the risk for infections, woundrupture, anastomotic leakage, and wound and flapnecrosis and decreases wound tensile strength.

• Alcohol consumption increases susceptibility toinfection and impairs angiogenesis (eg, growth of newblood vessels).

• Malnutrition: impairs wound healing as a result ofinadequate intake of dietary protein.

• Systemic steroid medications cause wounds to healwith incomplete granulation tissue and reduced woundcontraction.7

• Chemotherapeutic medication delays cell migrationinto the wound, decreases early wound matrixformation, lowers collagen production, impairsproliferation of fibroblasts, and inhibits woundcontraction.8

• Chronic diseases and immunocompromisedconditions (eg, diabetes) delay wound healing.

Diabetes mellitus is one of the most prevalent patient-specificrisk factors for delayed wound healing or non-healing. Thisdisease affects an estimated 8.3% of the US population andabout 27% of US adults aged 65 years and older.9 Diabetesmellitus is caused by insufficient levels or response to thehormone insulin and is characterized by high blood glucoselevels. Diabetes is associated with serious complications suchas blindness, kidney failure, heart and blood vessel disease,stroke, and premature death.9,10 It is the seventh leading causeof death in the United States.9

Diabetic foot ulcers affect an estimated 15% of patients withdiabetes mellitus and are the leading cause of non-traumaticlower limb amputation.8,11 Factors contributing to non-healing


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foot ulcers include defective T-cell immunity; impairedleukocyte chemotaxis, phagocytosis, and bactericidal activity;diminished peripheral circulation; decreased localangiogenesis; and neuropathy.

The key diagnostic test for diabetes is a fasting glucose level.A fasting glucose level of 70 to 100 mg/dL is considerednormal.12 Patients with levels between 100-125 mg/dL haveimpaired fasting glucose, a type of prediabetes. Impairedfasting blood glucose is considered a risk factor for type 2diabetes mellitus and its complications. Diabetes is diagnosedin persons with fasting blood glucose levels that are 126mg/dL or higher. An impaired glucose tolerance (IGT), a 2-hour post-meal glucose level between 140 and 199 mg/dL, isalso considered a risk category for diabetes mellitus.

Patients with type 1 diabetes mellitus have an absolutedeficiency of insulin because of insufficient production of thishormone by pancreatic beta cells.13 In contrast, patients withtype 2 diabetes mellitus have a condition known as insulinresistance, which occurs when insulin no longer acts normallyon target tissues and compensatory insulin secretory responseis inadequate. Additional causes of diabetes include pregnancy(ie, gestational diabetes), genetic defects, surgery, and drug-induced hyperglycemia.

Perioperative patients with diabetes mellitus are at risk fornumerous potential complications. Degeneration of smallblood vessels can occur in many organs, leading to a range ofmedical problems. Other complications of diabetes mellitusinclude delayed wound healing, hyper- or hypoglycemia,hypertension, surgery-related pressure ulcers, and increasedrisk of SSI or other infections.14-16

Glucose is a major source of energy for most cells of the body,including the brain. Because stress increases blood glucoselevels, both diabetic and non-diabetic patients may have veryhigh blood sugars in the perioperative period, and cliniciansshould perform frequent blood glucose monitoring.17

Perioperative factors also affect wound healing. Forexample, many surgical patients are at risk for unplannedhypothermia in the relatively cool environment of the ORsuite. Hypothermia causes peripheral vasoconstriction, whichcan compromise wound healing.18 Perioperative RNs shouldimplement measures that assist the patient in maintainingnormothermia during operative procedures.19,20 Otherexamples of perioperative factors that affect wound healinginclude adherence to sterile technique and limiting theduration of surgery and the amount of traffic and number ofpersons in the OR.21,22

SURGICAL SITE INFECTIONS

The most common cause of impaired wound healing insurgical patients is a surgical site infection (SSI). Leftuntreated, SSIs can progress and cause serious complicationsincluding delayed healing, nonhealing, systemic infection, andeven death. Surgical site infections are also associated withan increased risk for revision surgery, antibiotic therapy, andprolonged hospital stays, which can adversely affect patients’quality of life and add substantially to health care costs.23 Theincreasing prevalence in healthcare settings of antibiotic-resistant bacterial pathogens, such as methicillin-resistantStaphylococcus aureus (MRSA) and vancomycin-resistantenterococci (VRE) have increased the need to prevent SSIs.24These resistant pathogens are associated with poor outcomesand major increases in health care costs.

Diverse factors affect the risk of SSIs, including the:23

• patient’s underlying susceptibility to infection;• severity of the primary disease or condition and number

and severity of comorbid conditions;• the correct type, dose, timing, and route of antimicrobial

prophylaxis administered when indicated;• exposure of the incision to environmental contaminants

or the patient’s own microflora;• adherence to sterile technique; and• implemented surgical techniques that minimize tissue

damage, eliminate dead space, and reduce the amountof time the operative wound is exposed to air.

Prevention of SSIsBefore an operative or other invasive procedure, patients maybe instructed to follow a series of essential practices to reducethe risk of SSIs. Clinicians often instruct patients to showerwith soap or with an antiseptic solution before the procedureto cleanse the skin at the incision site. This practice helps


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reduce the microbial load at the site, thus decreasing the riskof infection.25

Patients also may undergo a complete preoperative history andphysical assessment, which may include laboratory and otherdiagnostic testing. This assessment and testing can identifyabnormal laboratory values and other indicators of underlyingconditions that could increase the risk of postoperativeinfection.

On the day of surgery, the procedure room should be preparedby perioperative personnel following AORNrecommendations for environmental cleaning and using steriletechnique when opening instrument packs, drapes, and othersupplies.22,26 Additionally, the perioperative team shouldfollow recommended hand hygiene protocols.27 If a surgicalsite requires hair removal, clipping is recommended, ratherthan shaving, to reduce the risk of opening the epidermis atthe surgical site and increasing susceptibility to infection.21

The perioperative team’s coordinated efforts to prevent SSIsshould continue in the operative suite. Perioperative RNsshould perform preoperative skin antisepsis of the surgical siteto remove soil and transient microorganisms from the skin,reduce the microbial count to sub-pathogenic levels, andinhibit growth of microorganisms.21All team members shouldpractice strict adherence to sterile technique, monitor forbreaks in sterile technique, and be prepared to immediatelycommunicate about and correct breaks if they occur.22 Theteam should also wear correct surgical attire to reduce thelikelihood of lint and other particles contaminating theincision.28 The RN circulator should monitor traffic and thenumber of persons in the OR should be kept to a minimum toreduce air currents that could contaminate the surgical site.22,29The team should monitor the patient’s physiological statuscarefully and take steps to promote normothermia andsufficient oxygenation.19 Additionally, the surgeon shouldpractice good surgical technique by working carefully andefficiently to reduce the amount of trauma to the tissues andthe time that the open incision is exposed to air. At the end of

the surgical procedure, perioperative RNs should determineand document the surgical wound classification according tothe CDC Surgical Wound Classification system.3,30 When theoperative procedure is completed, the surgical incision shouldbe protected with sterile dressings that remain over the site for24-48 hours postoperatively.32

Wound classificationThe CDC Surgical Wound Classification system is used toclassify wounds based on the likelihood and degree of woundcontamination at the time of surgery. It is important to notethat if there is no wound, there is no wound classification (forexample, in a closed reduction of a fracture, or examinationand manipulation of a joint under anesthesia).

The four wound classifications are:3,30,32

• Class 1 (Clean)• Class 2 (Clean-contaminated)• Class 3 (Contaminated)• Class 4 (Dirty or Infected)

Class 1- Clean wounds are uninfected operativewounds in which no inflammation is encountered, andthe respiratory, alimentary, genital, or uninfectedurinary tracts are not entered. In addition, class 1wounds are primarily closed, and, if necessary, aredrained with closed drainage. Operative incisionalwounds that follow non-penetrating (blunt) traumashould be included in this category if they meet thesecriteria. An example of a Class 1/clean procedure is atotal hip replacement.Class 2- Clean-contaminated wounds are operativeincisions in which the respiratory, alimentary, genital,or urinary tracts are entered under controlledconditions without evidence of infection orcontamination. Examples of Class 2/clean-contaminated procedures include operativeprocedures where the biliary tract, appendix, vagina,bladder, and oropharynx are entered, provided thatthere is no evidence of infection or major break insurgical technique, such as spillage from thegastrointestinal tract.Class 3- Contaminated wounds include open, fresh,accidental wounds, wounds associated with operativeprocedures in which there was a major break in steriletechnique, procedures where there was gross spillagefrom the gastrointestinal tract, or incisions in whichacute, nonpurulent inflammation is encountered. Anexample of a Class 3/contaminated procedure is an


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operative procedure performed with unsterileinstruments. Class 4- Dirty or infected wounds are old traumaticwounds with retained devitalized tissue, existingclinical infection (e.g. purulence), or perforatedviscera. The definition suggests that the organismscausing postoperative infection were present in theoperative field before the operation. An example of aClass 4-Dirty, infected procedure is a surgical incisionand drainage of an abscess.

These surgical wound classifications reflect the likelihood thatwound infection will occur. Wound classification allows forcomparison of wound infection rates associated with differentsurgical techniques, surgeons, and facilities.30 Thiscomparison is not only useful for research, but may also serveto alert infection prevention personnel regarding wounds atincreased risk for infection, which could enable health careproviders to implement surveillance and preventativemeasures.32

Each surgical wound should be evaluated and classifiedindependently and documented by the perioperative RN in thepatient record after the operative procedure. The AORN

Surgical Wound Classification Decision Tree is designed toenable perioperative nurses to accurately classify surgicalwounds based on the CDC surgical wound classificationsystem.33 The decision tree asks a series of yes or no questionsthat enable perioperative nurses to accurately classify woundsbased on the descriptions in the CDC classification system.When using the decision tree, it is important for theperioperative RN to keep in mind that incisions from similaroperative procedures might be classified differently based onfactors such as whether the genitourinary tract was entered;whether infection was encountered during the operativeprocedure; or other considerations related to surgical woundclassification.34

Patients, support persons, and home care providers usually areresponsible for the majority of wound care after operativeprocedures. Therefore, postoperatively, patient and caregivereducation is very important. Perioperative RNs need toeducate patients and their support person about warning signsof infection such as redness, marked swelling, fever, andpurulent discharge or foul odor at the incision site. Patientsand support persons should also be instructed verballyregarding hand washing techniques, dressing changes, andpatient restrictions on bathing and showering. Sending writtendirections home with the patient or support person helps toreinforce these important messages.

Perioperative RNs are positioned to serve as leaders in SSIprevention within many health care organizations. However,studies point to the need for improved patient education effortsin this area. In a survey of surgical patients, 26% ofrespondents thought that education regarding SSIs could beimproved, 16% could not remember discussing SSI risks andprevention with any health care worker, and only 60% recalledreceiving written information about SSIs from the health carefacility.35

CATEGORIES OF SSIsSSIs are categorized by the affected tissues.32,36


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Superficial incisional SSIs occur within 30 days after theoperative procedure, involve only the skin and subcutaneoustissue of the incision, and have at least one of the following:36

• Diagnosis of superficial incisional SSI by thephysician or attending surgeon

• Purulent drainage from the incision site• Organisms cultured aseptically from tissue or fluid

obtained from the superficial incision• Pain or tenderness, localized swelling, redness, or heat

at the surgical siteIf a superficial incisional infection is present, the surgeondeliberately opens the superficial incision to allow drainage,unless the incision is culture-negative.

In deep incisional SSIs, infection occurs within 30 or 90 daysof the operative procedure, the infection involves deep softtissues such as fascial and muscle layers of the incision, andmust meet one of the following criteria:36

• The attending surgeon or physician has diagnosed theinfection as a deep incisional SSI.

• There is purulent drainage from deep tissues but notthe organ/space component of the surgical site.

• A detectable abscess is present and/or the patientexperiences spontaneous dehiscence, or the surgeondeliberately opens the surgical site when the patienthas fever, localized pain, and/or tenderness (unless thesite is culture-negative).

Organ/space SSIs are defined as infection within 30 or 90days of the operation.36 Additionally, the infection mustinvolve a part of the anatomy, other than the incision, that wasopened or manipulated during the operation and must meet atleast one of the following criteria:

• There is purulent drainage from a drain placed into theorgan or organ space;

• Clinicians have cultured organisms from anaseptically obtained sample of fluid or tissue in theorgan or organ space;

• Detectable abscess or other sign of infection involvingthe organ or organ space is present, or

• The surgeon or attending physician has diagnosed anorgan or organ space SSI.

PERIOPERATIVE WOUND TREATMENTSTopical Hemostatic Products.Wound healing begins withhemostasis. Many methods are used to stop bleeding duringsurgery and may include applying pressure, suturing or usingelectrocautery on bleeding vessels or tissue, and administeringblood and blood products. When traditional methods areineffective or not feasible to attain hemostasis, surgeons maychoose to apply a topical hemostatic product to help controlbleeding.37 These products can also potentially reduce totalprocedure time and promote faster patient recovery.38

Passive or mechanical hemostatic agents are applied at thebleeding site and rely on the normal clotting cascade to work.They provide a barrier to stop blood flow and a surface thatenables blood to clot more rapidly.39 Examples of passivehemostatic agents include collagens (AviteneTM sheet andflour, UltrafoamTM, Helistat®, Helitene®, and Instat®),cellulose (Surgicel®, Surgicel Fibrillar®, and Nu-Knit®),gelatins (porcine gelatins include Gelfoam® sponge andpowder, and Surgifoam® sponge and powder), andpolysaccharide spheres (Arista®, Hemostase®, and Vitasure®).

Active hemostatic agents contain thrombin and productsmixed with thrombin. They act at the end of the coagulationcascade to enhance clotting at the bleeding site.38 Activehemostatic agents made from human and bovine sources, andrecombinant thrombins are licensed for clinical use in theUnited States. Specific products available in the United Statesinclude Thrombin, Topical, Bovine Origin (Thrombin-JMI®);Thrombin, Topical, Human (EvithromTM OmrixTM Bio-


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pharmaceuticals, Ltd); and Thrombin, Topical, Recombinant(RecothromTM ZymoGenetics, Inc).

Flowables are combinations of passive and active hemostaticagents that mechanically obstruct the flow of blood andactively convert fibrinogen in blood into fibrin at the site ofbleeding. Because flowables do not contain fibrinogen, theyrequire direct contact with blood to provide the fibrinogen forconversion into fibrin.39 Flowables may be made of bovinegelatin and pooled human thrombin (Floseal®), or porcinegelatin with or without thrombin (Surgiflo®).

Fibrin sealants promote blood clotting by supplementing thepatient’s own clotting factors, speeding up local coagulation,and catalyzing the activation and aggregation of platelets andformation of fibrin.40 The fibrin in these products is derivedfrom pooled or individual human plasma, equine or bovinecollagen, and bovine thrombin.40 Synthetic sealants are alsolicensed for clinical use.40 They are made from polyethyleneglycol polymers and cyanoacrylates. Specific products includeTisseel®, Tachosil®, Vitagel®, Coseal®, Duraseal®, Bioglue®,and OmnexTM.

It is important to keep in mind that patients can have adversereactions to topical hemostatic agents as a result of allergiesor previous sensitization.41 The most immediate risk isanaphylaxis resulting from allergies or previous sensitizationto immunogenic substances. Bloodborne pathogen infectionis also a risk when patients are exposed to products derivedfrom blood, although this risk has decreased with improveddonor screening programs.41,42 It is important to follow themanufacturer’s written directions for preparing the topicalhemostatic product for patient use or delivering it to the sterilefield.

Growth factors. Growth factors are naturally occurringpeptides and cytokines, that are sometimes used in woundcare.1 These soluble proteins help initiate and direct themitosis (cellular division) of fibroblasts, smooth muscle cells,epidermal cells, and vascular endothelial cells, all of which

are central to wound healing.1 Both human and recombinantgrowth factors are used in wound care and management.1Platelet-derived growth factors are extracted from 50 to 200mL of venous blood.1 The platelets are separated out andactivated with thrombin to create a gel. The gel is applied tothe clean wound bed.

Irrigation. This is an important practice for cleaning andhydrating wounds, preparing the wound bed for furthertreatment, and allowing care providers to better visualize thewound.43 Irrigating a wound through a continuous or pulsedrelease of fluid to the wound surface serves to flushcontaminants and nonviable tissue from the wound. Sufficientpressure and volume of irrigation fluid are needed to achievegood results, but care also must be taken to minimize damageto healthy tissue. One study found that excessive irrigationpressure during acute orthopedic surgery was associated withvisibly damaged bone, bacterial contamination of themedullary cavity, and delayed fracture healing.44 The volumeof irrigating solution should be adjusted based on the size ofthe wound and the extent of contamination, and the edges ofthe wound may need to be separated to fully irrigate the tissue.After irrigation, the wound should be examined, andadditional irrigation should be performed if necessary to flushremaining contaminants and dead tissue from the site. Someoptions for irrigation solutions include normal saline, sterilewater, and commercial wound cleansers.


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Incision and drainage.This is performed to release pus froman abscess.1 To perform incision and drainage, the clinicianantiseptically prepares the skin and uses a sterile instrumentto make a small incision. He or she deepens the incision untilpus is observed, and then explores and enlarges the incisionwith a surgical instrument. Specimens are often taken forculture and the surgeon can use a gloved finger to break upany loculations (i.e., sealed pockets of pus). The surgeonenlarges the wound to ensure sufficient drainage, and mayloosely pack it with gauze or place a drain. After treatment,the wound is often left open to heal by granulation. In somecases, incision and drainage are very painful, and may beperformed under general anesthesia.1

Debridement. This is performed to remove dead anddevitalized tissue from a wound and facilitates wound healingand closure.1,45 If nonviable tissue is not debrided and remainsin the wound, it can impede healing and serve as an infectionnidus (i.e., a place for infection to begin).1

Methods of debridement include mechanical methods such aspressure irrigation; surgical debridement with a scalpel orscissors; application of debriding agents with enzymatic actionthat contain collagenase; and biologic methods such as sterilemaggot debridement therapy.1 Each approach has benefits andrisks; for example, surgical debridement can result inbacteremia as bacteria at the wound site enter the bloodstream.Wounds that lack intrinsic, extrinsic, or mechanical damagemay be closed immediately after debridement.45 If thedebrided wound is not immediately closed and is left to healby secondary intention, follow-up assessment is required.Debrided wounds also may require secondary debridement tooptimize healing.45

Negative pressure wound therapy. This therapy, whichemerged in the late 1990s, is another technique that can beused to facilitate wound healing. In negative pressure woundtherapy, the wound is filled with one or more sterile spongesand sealed with occlusive dressing material.1 The negative

pressure wound therapy device, which is a closed, sealedsystem, promotes evacuation of excess fluid via suction tubesinto a liquid waste collector.46

This therapeutic modality has been used for many types oflesions including open abdominal wounds, skin graft donorsites, open fractures, acute burns, pressure ulcers, trauma-induced wounds, diabetic foot ulcers, split-thickness skingrafts, sternal wounds, and in type 1 (i.e., clean) wounds inobese patients.46 Furthermore, indications for the use ofnegative pressure wound therapy are increasing as morenegative pressure wound therapy systems enter the market.

Negative pressure wound therapy can potentially reduce therisk of SSI and expedite healing.47,48 Potential adverse effectsof this modality include pain and skin damage.49 Patients havealso reported concerns about decreased mobility, sleepdisturbances, and the noise created by these systems. Toprevent and minimize adverse outcomes, negative pressurewound therapy devices should be used by personnel withverified competency in their use. In addition, it is importantnot to cut sponges directly over the wound, to carefullymonitor the number and sizes of sponges placed in the wound,follow the health care organization’s protocols for patientassessments, and follow the manufacturer’s instructions forcorrect pressure ranges.

Skin substitutes. These materials are created by placinghuman cells onto matrixes of collagen or synthetic materials.1


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The human cells then grow and divide, secreting growthfactors that trigger cellular migration into the wound field andin turn promote epithelialization and revascularization.1Because of these characteristics, skin substitutes can be usefulas a temporary bridge to permanent closure of burns and othercomplex wounds, such as chronic ulcers. Skin substitutes alsomay be used to cover skin graft donor sites. Both biologicaland synthetic skin substitutes are available. Examples ofspecific skin substitute products include Biobrane®,Dermagraft®, TransCyte®, Apligraf®, AlloDerm®, Oasis®, andIntegra®. Different products are approved for different uses,such as diabetic foot ulcers or superficial burns. Skinsubstitutes can provide relatively long-term wound coverageand also have the advantage of being compatible withautologous tissue, readily commercially available, andassociated with fewer risks of adverse effects involving thedonor area.1

Drains. Drains provide an exit for serum, blood, lymph,intestinal secretions, bile, and pus from the operative site.1They may also be used to prevent deep wound infections.Drains are most commonly made from latex, polyvinylchloride (PVC), or silicone. It is important to ensure thatpatients are not latex-sensitive before placing latex drains. Thesurgeon usually inserts a drain at the time of surgery througha separate small incision called a stab wound near the primaryincision. In some cases, he or she may suture the drain to theskin.

Simple drains permit free flow through the drain onto adressing. An example is a Penrose drain in which fluidflows along the outside of the drain onto a dressing bymeans of gravity and capillary action. A T-tube drainis also a simple drain.1

Closed drainage systems are airtight circuits that helpprevent environmental contamination of the drainagesite. They are portable, self-contained, closed woundsuction systems, and use suction to pull drainage fromthe wound into a collection unit.1 Jackson-Pratt andHemovac® systems are closed drainage systems.

Chest drainage systems are designed to drain air, blood,pus, or lymph from the pleural cavity; prevent fluidand air from re-entering the pleural cavity; and enablethe patient’s lungs to re-expand and restore normalnegative intrapleural pressure.1A water-seal containeris connected to the chest tube to allow one-waymovement of liquid and air out of the pleural cavity.Changing or emptying the container should beaccomplished according to the manufacturer’sinstructions and the health care organization’s policyand procedure.

Dressings. These help protect the site of a wound frominfection or further injury.1 Dressings have several functions,including absorption of drainage, providing an environmentthat promotes healing, and provision of a mechanism to applymedications. Dressings also are used to support, splint, andimmobilize injuries, and are used in some cases for aestheticreasons. Dressings come in many options including:

The surgeon places a primary dressing directly over thewound or in the wound and these are usually made of anonadherent material. A secondary dressing is placed overthe primary dressing to absorb excessive drainage and providehemostasis. The secondary dressing is bulkier than theprimary dressing and helps protect the wound.

Numerous types of dressing materials are available, including

• cotton mesh gauze, nonadherent dressings (e.g.,Telfa®, Adaptic®, scarlet red gauze, Xeroform®);

• transparent films (e.g., Bioclusive®, Opsite®,Tegaderm™);

• hydrocolloid dressings (e.g., Comfeel®, Sorbex®,DuoDERM®, Tegsorb™);

• hydrogel (e.g., Carrasyn®, SoloSite Gel®, NU-GEL®,Curagel™, Vigilon®);

• alginates (e.g., AlgiDerm®, Algosteril®, Curasorb™,SeaSorb®, Kaltostat®, Sorbsan™);

• foam (e.g., Lyofoam®, KendallTM Foam, Allevyn™,Flexzan™, BioPatch™, VigiFOAM®);

• silicone (e.g., Cica-Care® Silicone Gel Sheeting,Mepiform®, Oleeva®);

• collagen (e.g., FibracolTM Plus, Promogran™,Cellerate RX™, Biostep®, Catrix®, ColActive®,Collieva®, Biopad®); and

• composites (Alldress®, Primapore®, OpSite™ Post-Op, Dermasil™).


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Despite this variety of available dressing materials, currentresearch does not definitively support the use of one type ofdressing over another. In a meta-analysis of 16 controlled trialsinvolving 2,594 patients, researchers found no evidence thatany one type of dressing significantly reduced the risk of SSIsor reduced the risk of pain or scarring compared with othertypes.50 However, the researchers also concluded that resultswere unclear or at high risk of bias.

Postoperative care for some operative procedures includessterile dressing changes.1 Dressing changes that cause thepatient substantial pain may require anesthesia. Examplesinclude dressing changes in patients who have extensive burninjuries or who have traumatic abdominal wounds that wereclosed by tertiary intention with placement of a negativepressure wound therapy device. Such patients could requireseveral surgeries to change the dressings as the wound heals.

Collodion is a topical, flexible occlusive dressing for use onsurgical incisions.51 Before using collodion, the care providershould confirm that patients are not allergic to ether, alcohol,or cellulose-based products. Because collodion is a mixtureof ethyl alcohol (22%) and ether (67%), it is EXTREMELYFLAMMABLE. Lasers and electrosurgery devices should notbe activated in the presence of flammable agents such ascollodion until the agents are dry and the vapors havedissipated.52,53 Care providers should follow themanufacturer’s instructions for use, be familiar with the SafetyData Sheets about the product, and follow the facility’spolicies regarding storage and use of collodion.54Perioperative personnel should follow local and state fireregulations regarding the storage of flammable liquids suchas alcohol-based skin antiseptic solutions, hand sanitizers,alcohol, acetone, and collodion and the location ofdispensers.29

Casts, splints, and braces are used to help protect andimmobilize extremities during wound healing.1 For example,a femoral cast brace might be placed after orthopedic surgeryto repair a femoral shaft fracture, or a short arm cast might beplaced to immobilize and protect a radial fracture while itheals. Splints or casts are made from plaster or fiberglass.Padding is placed between the skin and the splint or cast toprotect the skin and prevent skin burns or damage from plastercasting materials that produce heat as they harden.

Before and after an operative procedure in which a cast, splint,or brace is placed, to the perioperative RN should assess anddocument the patient’s circulation, motion, and sensation(CMS check) in the affected extremity. After surgery, theimmobilized limb is usually elevated with pillows or foampadding devices which promotes venous return and helps

prevent edema.

Patient education is an important aspect of nursing care forpatients with casts, splints, or braces. Perioperative RNsshould instruct patients not to remove casts or splints unlessthey are told to do so by a physician.1 Patients also need tounderstand whether and in what manner bathing or showeringis permitted; and to communicate with their health careprovider if they experience signs of impaired circulation andnerve compression of the affected extremity (e.g., pain, lackof easily detectable pulse, pallor, pressure, poikilothermia55[inability to maintain a constant core temperature], tingling orburning, inability to move muscles around the cast); and signsand symptoms of infection (e.g., drainage or a foul odor nearthe cast’s edges).56

Patients should also be instructed to practice good skin carearound the cast and not to insert objects (e.g., coat hangers),creams, lotions, or powder under the cast.

COMPLEX WOUND CAREThe term complex wound is used to refer to wounds that arechallenging and costly to treat and require individualized,coordinated approaches to wound management.57 Thiscategory of wounds includes ostomies, chronic venous ulcers,ulcers associated with vasculitis or diabetic neuropathy, deeppressure sores, traumatic or necrotizing wounds, burns, post-radiation wounds, and complicated surgical wounds.55

Complex wounds may require an individualized treatmentapproach using advanced wound care therapies developed bya multidisciplinary team. Surgery is sometimes indicated forcomplex wounds. Debridement may be performed to removenonviable tissue, while grafts or tissue flaps may be used toreconstruct lost skin and subcutaneous tissue.58 Othertherapies for complex wounds include the use of biologicalskin equivalents and negative pressure wound therapy.59 Somepatients with complex wounds also benefit from nutritionaland behavioral counseling to help them understand and copewith the need for ongoing care at home.

PEDIATRIC WOUND CAREMany of the principles of adult wound care also apply toinfants and children. However, some aspects of wound caremust be tailored because of physiological and developmentaldifferences between children and adults. For example, infantsand young children may not be able to verbally express pain,which can increase the risk of pressure sores or frictionblisters.60 Additionally, the skin of infants is more susceptibleto epidermal tears and blisters, because their epidermis is onlyloosely attached to the underlying dermis.60 Children’s skin


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also is more sensitive to certain chemicals found in topicalproducts.60 Antiseptic solutions such as alcohol, povidoneiodine, and hydrogen peroxide can be cytotoxic and can delaywound healing, particularly in children.60

Children also may try to pull off wound dressings; thus,topical or paint-on products may provide superior woundprotection. Some children experience pain during applicationof tissue adhesives, and may benefit from a topical analgesicapplied before application of the tissue adhesive.61 Oneprospective study found that amniotic membrane was superiorto silver sulfadiazine in children with burn wounds.62 Use ofamniotic membrane was associated with reduced hospital stayand number of dressing changes. It is important to note thatdosages of topical wound care products intended for adultsshould be carefully evaluated and reduced when necessary forchildren.59 Furthermore, perioperative personnel need tofollow product manufacturers’ written instructions for use.

Surgical site infections are an important consideration inchildren and adolescents as well as adults. Studies indicatesurgeons and RN circulators classify pediatric woundsdifferently. In a single-center retrospective cohort study of 312pediatric appendectomy cases, the surgeon diagnosis-basedand RN circulator-based surgical wound classificationsdiffered in 92% of cases, and differed by more than oneclassification in 56% of cases.63 The researchers concludedthat such inconsistencies could significantly affect outcomemeasures, which could cause misdirection of quality-improvement efforts and incorrect inter-hospital ratings.Another small cross-sectional study reported poor consensusamong pediatric surgeons on the classification of incisions onneonates.64

Guidelines for prevention of specific types of SSIs may belacking in children even when available for adults, and theincidence rates of pediatric SSIs may be poorly understood orunderreported.65,66 Researchers conducting an online surveyof 89 congenital heart programs recently reported that theincidence of pediatric sternal wound infections was 1.53%.64The researchers also found that pediatric programs did not

consistently follow adult guidelines for SSI prevention. Basedon their findings, the researchers recommended protocol-based management of pediatric blood glucose levels andsending mediastinal wound cultures at the time of surgicalclosure.

Personnel at some health care facilities have implementedpediatric-specific measures to prevent postoperative woundcomplications. For example, nurses in the cardiac and mainORs at a major children’s hospital designed and implementeda tool to assess patient risk and plan nursing interventions toprevent pressure ulcers in pediatric surgery patients.67 Aprospective study indicated that use of the tool in conjunctionwith increased awareness and education regarding pressureulcer prevention, and a hospital-wide focus on skin carehelped to reduce pressure ulcers in pediatric surgery patients.67

COLLABORATIONCollaboration between health care team members can help toachieve optimal outcomes in wound care. Perioperative RNsprovide wound care in collaboration with a diverse range ofclinical providers, such as physicians and licensedindependent practitioners, infection preventionists, wound andostomy RNs, advanced practice nurses, and other health carepersonnel. Collaboration is always important, and is especiallyimportant in cases of chronic and complex wounds, such asvenous ulcers, which require the efforts of a multidisciplinaryteam to manage challenges and complications as they arise.68Collaboration is also essential for patients who have comorbidconditions such as diabetes or other risk factors for delayedhealing or non-healing.

SUMMARYPerioperative RNs and their colleagues should understand thecomplex physiology of wound healing; identify patient riskfactors that negatively affect wound healing; and implementevidence-based nursing practices for improved woundhealing. These practices include providing

• preoperative patient education and preparation;• intraoperative care, including maintaining sterile

technique and correctly classifying surgical wounds; • postoperative assistance in the treatment and

management of perioperative wounds; • collaboration and communication with clinical

providers involved in wound management; and• wound management education for patients .

Perioperative nurses play a key role in managing wound careand preventing SSIs in surgical patients.


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Editor’s note:Gelfoam and Floseal, are registered trademarks,and CoSeal and TISSEEL are trademarks of the BaxterCorporation, Deerfield, IL. BioGlue is a registered trademarkof Cryolife, Kennesaw, GA. Avitene and Ultrafoam, aretrademarks of the Davol/Bard Company, Warwick, RI.EVITHROM, INSTAT, SURGIFOAM, SURGIFLO,DERMABOND, SURGICEL, SURGICEL Microfibrillar,SURGICEL Nu-Knit, EVICEL, and SURGICEL SNoW, areregistered trademarks and OMNEX is a trademark of Ethicon,Johnson & Johnson, Inc, Somerville, NJ. Helistat is aregistered trademark of the Integra Life Sciences Corporation,Plainsboro, NJ. Vitagel is a trademark of Vitaprep Stryker,Malverne, PA. Progel is a registered trademark of Neomend,Irvine, CA. Thrombin-JMI is a registered trademark of Pfizer,New York, NY. Arista is a trademark of Medafor, Minneapolis,MN. Vitasure is a registered trademark of OrthoVita, Malvern,PA. DuraSeal is a trademark of Covidien, Boulder, CO.Recothrom is a registered trademark of The MedicinesCompany, Parsippany, NJ. SurgiSeal is a registered trademarkof Adhezion Biomedical, Wyomissing, PA. LiquiBand is aregistered trademark of Cardinal Health, Dublin, OH.CryoSeal is a registered trademark of the ThermoGeneis Corp,Rancho Cordova, CA. Helitene and Integra are registeredtrademarks of Integra LifeSciences Inc, Plainsboro, NJ.Tachosil TachoSil is a registered trademark of NycomedPharma AS, Zurich, Switzerland. Biobrane is a registeredtrademark of Bertek Pharmaceuticals Inc, Morgantown, WV.Dermagraft is a registered trademark of Organogenesis Inc,La Jolla, CA. TransCyte, Opsite, and SoloSite Gel areregistered trademarks of Smith & Nephew, St Petersburg, FL.Apligraf is a registered trademark of Organogenesis Inc,Canton, MA. AlloDerm is a registered trademark of LifeCell,Branchburg, NJ. Oasis is a registered trademark of CookBiotech Inc, West Lafayette, IN. Hemovac is a registeredtrademark of the Zimmer Inc, Warsaw, IN. Xeroform and Telfaare registered trademarks of Covidien, Mansfield, MA.Bioclusive and Adaptic are registered trademarks ofSystagenix, San Antonio, TX. Tegaderm is a trademark of 3M,St Paul, MN. Comfeel is a registered trademark of Coloplast,Minneapolis, MN. Sorbex is a registered trademark of MelroseChemicals, Lachine, QC, Canada. DuoDERM is a registeredtrademark of ConvaTec, Australia. Tegsorb is a trademark ofEvonik, Hopewell, VA. Carrasyn is a registered trademark ofCarrington Laboratories, Irving, TX. NU-GEL is a registeredtrademark of Life Technologies, Grand Island, NY. Curagel isa trademark of Tyko Healthcare, Mansfield, MA. Vigilon is aregistered trademark of Bard Medical, Louisville, CO.AlgiDerm is a registered trademark of OUC Medical, Tampa,FL. Algosteril is a registered trademark of Les LaboratoiresBrothier, Nanterre, France. Curasorb and Kendall Foam are

trademarks of Covidien, Mansfield, MA. SeaSorb is aregistered trademark of Coloplast Corp, Minneapolis, MN.Kaltostat is a registered trademark of ConvatecManufacturing, Bridgewater, NJ. Sorbsan is a trademark ofDow Hickam Pharmaceuticals, Houston, TX. Allevyn andOpSite are trademarks of Smith and Nephew, St Petersburg,FL. Flexzan is a trademark of Mylan Bertek Pharmaceuticals,Research Triangle Park, NC. BioPatch is a registeredtrademark of Ethicon, Blue Ash, OH. VigiFOAM is a registeredtrademark of Bard Medical, Covington, GA. Oleeva is aregistered trademark of BioMed Science, Allentown, PA.Fibracol Plus and Promogran are trademarks of Systagenix,San Antonio, TX. Cellerate RX is a trademark of WoundManagement Technologies, Fort Worth, TX. Biostep andPrimapore and Cica-Care Silicone Gel Sheeting are registeredtrademarks of Smith and Nephew, St Petersburg, FL. Catrix isa registered trademark of Lescarden, New York, NY. ColActiveis a registered trademark of Covalon Technologies, Ontario,Canada. Collieva is a registered trademark of BioCentury, SanCarlos, CA. Biopad is a registered trademark of AngeliniPharma, Gaithersburg, MD. Alldress and Mepiform andLyofoam are registered trademarks of Molnlyncke Healthcare,Norcross, GA. Dermasil is the trademark of Innocoll, Athlone,Ireland.


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REFERENCES1. Alexander’s Care of the Patient in Surgery. 14th Ed. Rothrock JC, ed. Mosby, 2011: 250-266; 735-736; 956-946.2. Mercandetti M, Cohen AJ. Wound Healing and Repair (2013). Available at:

http://emedicine.medscape.com/�article/�1298129-overview Accessed March 11, 2014.3. Guideline for Surgical Site Classification, 1999. The Centers for Disease Control and Prevention.

http://www.cdc.gov/hicpac/SSI/table7-8-9-10-SSI.html. Accessed August 29. 2014 4. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials

comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA Surg.2013;148(8):779-786.

5. Eliya MC, Banda GW. Primary closure versus delayed closure for non-bite traumatic wounds within 24 hours postinjury. Cochrane Database Syst Rev. 2011;(9):CD008574.

6. Jenkinson RJ, Kiss A, Johnson S, et al. Delayed wound closure increases deep-infection rate associated withlower-grade open fractures: a propensity-matched cohort study. J Bone Joint Surg Am. 2014;96(5):380-386.

7. Rodriguez-Merchan EC. Surgical wound healing in bleeding disorders. Haemophilia. 2012;18(4):487-490.8. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229.9. National Diabetes Statistics, 2011. National Diabetes Information Clearinghouse.

http://diabetes.niddk.nih.gov/dm/pubs/overview/#types. Accessed March 11, 2014.10. The Facts About Diabetes: A Leading Cause of Death in the U.S. National Diabetes Education Program.

http://ndep.nih.gov/diabetes-facts/. Accessed March 22, 2014.11 Pendsey SP. Understanding diabetic foot. Int J Diabetes Dev Ctries. 2010;30(2):75-79.12. Glucose test – blood. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm. Accessed

March 11, 2014.13. American Diabetes Association. Diabetes Care. Jan 2009; 32(Suppl 1):S62–S67.14. Wolfson TS, Hamula MJ, Jazrawi LM. Impact of diabetes mellitus on surgical outcomes in sports medicine. Phys

Sportsmed. 2013;41(4):64-77.15. Tsang ST, Gaston P. Adverse perioperative outcomes following elective total hip replacement in diabetes mellitus:

a systematic review and meta-analysis of cohort studies. Bone Joint J. 2013;95-B(11):1474-1479.16. Liu P, He W, Chen HL. Diabetes mellitus as a risk factor for surgery-related pressure ulcers: a meta-analysis. J

Wound Ostomy Continence Nurs. 2012;39(5):495-499.17. Rutan L, Sommers K. Hyperglycemia as a risk factor in the perioperative patient. AORN J. 2012;95(3):352-361.18. Horosz B, Malec-Milewska M. Inadvertent intraoperative hypothermia. Anaesthesiol Intensive Ther.

2013;45(1):38-43. 19. Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standards

and Recommended Practices. Denver, CO: AORN, Inc; 2014;431-442.20. Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN J. 2008;88(3):358-365.21. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended

Practices. Denver, CO: AORN, Inc; 2014;73-87.22. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver,

CO: AORN, Inc; 2014;89-117.23. Harrop JS, Styliaras JC, Ooi YC, et al. Contributing factors to surgical site infections. J Am Acad Orthop Surg.

2012;20(2):94-101.24. Hsu V. Prevention of health care-associated infections. Am Fam Physician. 2014;90(6):377-382.


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25. Kamel C, McGahan L, Polisena J, et al. Preoperative skin antiseptic preparations for preventing surgical siteinfections: a systematic review. Infect Control Hosp Epidemiol. 2012;33(6):608-617.

26. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2014;255-276.

27. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2014;61-72.

28. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO:AORN, Inc; 2014;49-60.

29. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices.Denver, CO: AORN, Inc; 2014;229-254.

30. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In:Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:385-420.

32. Mangram AJ, Horan TC, Pearson ML, Hospital Infection Control Practices Advisory Committee. Guidelines forprevention of surgical site infection. 1999. Am J Infect Control. 1999;27(2):97-132.

33. Surgical wound classification decision tree. AORN, Inc.http://www.aorn.org/Clinical_Practice/Clinical_FAQs/Supporting_Documents/Wound_Classification.aspx.Accessed March 11, 2014

34. Van Wicklin SA. Venous thromboembolism prophylaxis in pediatric patients; The Centers for Disease Control andPrevention surgical wound classification system; using the Surgical Wound Decision Tree tool; using cottonsurgical masks; using povidone-iodine solution for surgical skin antisepsis before thyroid procedures. [ClinicalIssues]. AORN J. 2012;95(1):155-163.

35. Anderson M, Ottum A, Zerbel S, et al. A survey to examine patient awareness, knowledge, and perceptionsregarding the risks and consequences of surgical site infections. Am J Infect Control. 2013;41(12):1293-1295.

36. Surgical Site Infection (SSI) Event. CDC. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. AccessedMarch 22, 2014.

37. Ozawa S. Patient blood management: use of topical hemostatic and sealant agents. AORN J. 2013;98(5):461-478.38. Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and

adhesives for maintaining hemostasis. Pharmacotherapy. 2013;33(9):935-955.39. Burks S, Spotnitz W. Safety and usability of hemostats, sealants, and adhesives. AORN J. 2014;100(2):160-176.40. Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and

adhesives for maintaining hemostasis. Pharmacother. 2013;33(9):935-955.41. Ofosu FA, Freedman J, Semple JW. Plasma-derived biological medicines used to promote haemostasis. Thromb

Haemost. 2008;99(5):851-862.42. Camp A, Hemostatic agents: a guide to safe practice for perioperative nurses. AORN J. 2014;100(2):132-144.43. Gabriel A. Wound irrigation. Medscape. http://emedicine.medscape.com/article/1895071-overview Accessed

March 11, 2014.44. Bahrs C, Schnabel M, Frank T, et al. Lavage of contaminated surfaces: an in vitro evaluation of the effectiveness

of different systems. J Surg Res. 2003;112(1):26-30.45. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation,

and closure considerations. Int J Emerg Med. 2010;3(4):399-407.46. Webster J, Scuffham P, Sherriff KL, et al. Negative pressure wound therapy for skin grafts and surgical wounds

healing by primary intention. Cochrane Database Syst Rev. 2012;4:CD009261.47. Bonds AM, Novick TK, Dietert JB, Araghizadeh FY, Olson CH. Incisional negative pressure wound therapy

significantly reduces surgical site infection in open colorectal surgery. Dis Colon Rectum. 2013;56(12):1403-1408.


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48. Monsen C, Wann-Hansson C, Wictorsson C, et al. Vacuum-assisted wound closure versus alginate for thetreatment of deep perivascular wound infections in the groin after vascular surgery. J Vasc Surg. 2014;59(1):145-151.

49. Andrews A, Upton D. Negative pressure wound therapy: improving the patient experience part 3 of 3. J WoundCare. 2013;22(12):671-672,674,676-678.

50. Walter CJ, Dumville JC, Sharp CA, et al. Systematic review and meta-analysis of wound dressings in theprevention of surgical-site infections in surgical wounds healing by primary intention. Br J Surg. 2012;99(9):1185-1194.

51. Rotenberg BW, Marchie A, Cusimano, MD. Skin sealants: an effective option for closing cerebrospinal fluidleakage. Can J Surg. 2004; 47(6):466-468

52. Recommended practices for laser safety in perioperative practice settings. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2014;141-154.

53. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver,CO: AORN, Inc; 2014:123-140.

54. Material Safety Data Sheet: Collodion. MVAPMed.http://www.mvapmed.com/MSDS_Forms/COLLODION%20%20USP%20EU.pdf. Accessed March 17, 2014

55. Mabvuure NT, Malahias M, Hindocha S, et al. Acute compartment syndrome of the limbs: current concepts andmanagement. Open Orthop J. 2012;6(need issue number):536-543.

56. MacKenzie MA, Hermus AR, Wollersheim HC, et al. Poikilothermia in man: pathophysiology and clinicalimplications. Medicine (Baltimore). 1991;70(4):257-268.

57. Ferreira MC, Tuma P Jr, Carvalho VF, et al. Complex wounds. Clinics (Sao Paulo). 2006;61(6):571-578.58. Coltro PS, Ferreira MC, Batista BP, et al. Role of plastic surgery on the treatment complex wounds. Rev Col Bras

Cir. 2011;38(6):381-386.59. Greer N, Foman NA, MacDonald R, et al. Advanced wound care therapies for nonhealing diabetic, venous, and

arterial ulcers: a systematic review. Ann Intern Med. 2013.15;159(8):532-542.60. McCord SS, Levy ML. Practical guide to pediatric wound care. Sem Plast Surg. 2006;20(3):192-199.61. Harman S, Zemek R, Duncan MJ, et al. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine

during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ. 2013;185(13):E629-E634.

62. Mostaque AK, Rahman KB. Comparisons of the effects of biological membrane (amnion) and silver sulfadiazinein the management of burn wounds in children. J Burn Care Res. 2011;32(2):200-209.

63. Levy SM, Holzmann-Pazgal G, Lally KP, et al. Quality check of a quality measure: surgical wound classificationdiscrepancies impact risk-stratified surgical site infection rates in pediatric appendicitis. J Am Coll Surg.2013;217(6):969-973.

64. Woodward CS, Son M, Calhoon J, et al. Sternal wound infections in pediatric congenital cardiac surgery: a surveyof incidence and preventative practice. Ann Thorac Surg. 2011;91(3):799-804.

65. Vu LT, Nobuhara KK, Lee H, et al. Conflicts in wound classification of neonatal operations. J Pediatr Surg.2009;44(6):1206-1211.

66. Toltzis P, O’Riordan M, Cunningham DJ, et al. A statewide collaborative to reduce pediatric surgical siteinfections. Pediatrics. 2014; pii: peds.2014 [Epub ahead of print]

67. Galvin PA, Curley MA. The Braden Q+P: a pediatric perioperative pressure ulcer risk assessment and interventiontool. AORN J. 2012;96(3):261-270

68. Langemo DK. Venous ulcers: etiology and care of patients treated with human skin equivalent grafts. J Vasc Nurs.1999;17(1):6-11.


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69. Prevention Strategies: Core Intraoperative Measures slide 17.http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf. Centers for Disease Control andPrevention. Accessed June 13, 2014.


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1. A shoulder examination under anesthesia is anexample of what class of wound?a. Class 1b. Class 2c. Class 3d. No wound classification

2. The most common cause of impaired wound healingin surgical patients isa. diabetes mellitus.b. inadequate dietary protein intake.c. intraoperative hypothermia.d. surgical site infections.

3. Which physiologic response to wounding isprimarily characterized by granulation tissue, neo-vascularization, and re-epithelialization?a. Hemostasisb. Inflammatory phasec. Proliferative phased. Remodeling phase

4. An advantage of closure by secondary intention isa. ability to clean the wound surface.b. faster healing.c. less scarring.

5. A patient presents 10 days after hernia repair with afever of 101º F (38.3º C). The suture line haspartially dehisced and you observe purulentdischarge from the tissue underlying the incision.What kind of surgical site infection is this mostlikely to be?a. Deep incisionalb. Organ or spacec. Superficial incisional

6. Choose the TRUE statement about topicalhemostatic products.a. Active hemostatic products include cellulose

and gelatins.b. Fibrin sealants increase levels of fibrinogen and

thrombin at a bleeding site.c. Flowables contain fibrinogen.d. Passive or mechanical hemostatic products

contain thrombin.

7. A Penrose drain is an example of aa. chest drainage system.b. closed drainage system.c. simple drain.

8. Choose the TRUE statement about dressings.a. Certain dressings are definitively associated

with improved outcomes.b. Primary dressings are bulkier than secondary

dressings.c. Primary dressings are usually made of adherent

material.d. Secondary dressings absorb discharge, protect

wounds, and promote hemostasis.

9. Ostomies, burns, chronic venous ulcers, andnecrotizing wounds are examples ofa. class 1 wounds with low risk of infection.b. complex wounds that require individualized

treatment.c. superficial surgical site infections that require

antibiotic therapy.d. wounds that require delayed primary closure.

10. Use of the Center for Disease Control andPrevention’s Surgical Wound Classification Systema. adds significant time to operative procedures.b. enables comparison of infection rates and

assessment of infection risk.c. is recommended primarily for complex or high-

risk wounds.d. must be performed by a surgeon.

POST-TEST


Multiple choice. Please choose the word or phrase that best completes the following statements.

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1.d2.d3.c4.a5.a6.b7.c8.d9.b10.b

POST-TEST ANSWERS


WOUND CAREAND HEALING IN PERIOPERATIVE PRACTICE...provide wound care in collaboration with a diverse...

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