Wound Management

Guidelines for wound management: 

o Promote a multidisciplinary approach to care.

o Initial patient and wound assessment is important and whenever there is a change
in condition.
o Consider the psychological implications of a wound- especially relevant in the
paediatric setting in relation to developmental understanding and pain associated
with the wound and dressing changes.
o Determine the goal of care and expected outcomes.
o Respect the fragile wound environment.
o Maintain bacterial balance- use aseptic technique when performing wound
procedures.
o Maintain a moist wound environment
o Maintain a stable wound temperature. Avoid cold solutions or wound exposure.
o Maintain an acidic or neutral pH.
o Allow a heavily draining wound to drain freely.
o Eliminate dead space but don’t pack a wound tightly.
o Select appropriate dressings and techniques based on assessment and scientific
evidence.
o Instigate appropriate adjunctive wound therapies- e.g. compression, splinting and
pressure redistribution equipment, off-loading orthotics.
o Follow the principles for managing acute and chronic wounds. (Carville, 2017)

Acute Wound Management

Wound cleansing

The goal of wound cleansing is to:

o Remove visible debris and devitalised tissue

o Remove dressing residue
o Remove excessive or dry crusting exudates
o Reduce contamination 

Principles of wound cleansing:

o Use Aseptic Technique procedure- a non-touch technique is used to protect key

parts and key sites. If a key part or key site is to be touched directly then sterile
gloves must be worn. Note: when using a disinfectant on a key site (e.g. skin) or
key part (e.g. injection port) it must be allowed to dry. 
o Cleansing should be performed in a way that minimises trauma to the wound as
new epithelial cells and vessels are fragile.
 o Irrigation is the preferred method for cleansing open wounds. This may be carried
out utilising a syringe in order to produce gentle pressure and loosen debris.
Gauze swabs and cotton wool should be used with caution.
o Wounds are best cleansed with sterile isotonic saline or water, warmed to body
temperature.

Choice of dressing

A wound will require different management and treatment at various stages of healing.
No dressing is suitable for all wounds; therefore frequent assessment of the wound is
required. 

Wound healing progresses most rapidly in an environment that is clean, moist (but not
wet), protected from heat loss, trauma and bacterial invasion.

o Much research has demonstrated that moisture control is a critical aspect of

wound care.
o The appropriate dressing can have a significant effect on the rate and quality of
healing.
o The appropriate dressing will help to minimize bacterial contamination and pain
associated with wound care.

There are a multitude of dressings available to select from. Effective dressing selection
requires both accurate wound assessment and current knowledge of available dressings
(Ayello, Elizabeth A)

Wounds healing by Primary Intention

These wounds require little intervention other than protection and observation for
complications.
Recommended dressings include:

o Dry non-adherants
o Island dressings
o Semi-permeable films
o Hydrocolloids
o Foams

Wounds healing by delayed primary intention

Occurs when the wound is contaminated or infection is suspected. These traumatic or

surgical wounds require intensive cleaning before healing can occur. Debridement using
irrigation may be required.
Recommended dressings include:

o Normal saline compresses

 o Amphorous hydrogels or hydrogel impregnated gauzes to assist with debridement
o Calcium alginate ropes or ribbons
o Hyrofibre ropes or ribbons
o Drainable wound/ostomy appliances when large amounts of exudate is present
o Foams

Absorbent or protective secondary dressings will be required for most wounds- it is

important to ensure that the surrounding skin is protected from maceration. A skin barrier
wipe can be used.

Wounds healing by secondary intention

Acute surgical or traumatic wounds may be allowed to heal by secondary intention- for
example a sinus, drained abscess, wound dehiscence, skin tear or superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to Stomal
Therapy should be considered to promote optimal wound healing.

Table 3: Surgical Wound Descriptions

1. Newly epithelialized:
. wound bed completely covered with new epithelium
. no exudate
. no avascular tissue (eschar and/or slough)
. no signs or symptoms of infection
2. Fully granulating:
. wound bed filled with granulation tissue to the level of the surrounding skin
. no dead space
. no avascular tissue (eschar and/or slough)
. no signs or symptoms of infection
. wound edges open
3. Early/partial granulation:
≥25% of wound bed covered with granulation tissue
. < 25% of wound bed covered with avascular tissue (eschar and/or slough)
. no signs or symptoms of infection
. wound edges open
4. Not healing:
. wound with ≥25% avascular tissue (eschar and/or slough), OR
. signs/symptoms of infection, OR
. clean but non-granulating wound bed, OR
. closed/hyperkeratotic wound edges, OR
. persistent failure to improve despite appropriate comprehensive wound management

1.2 Identify risk and causative factors that may impact skin integrity
and wound healing.
Discussion: Performing a thorough and holistic pre-operative assessment will identify any
patient-specific risk factors that can be addressed in preparation for surgery. When
the surgery is emergent and risk factors cannot be addressed before the intervention, it is
important to identify any intrinsic and extrinsic factors that can be mitigated in the post-operative
period and to intervene as soon as possible.
1.2.1 Patient: Physical, emotional and lifestyle
Discussion: Knowing which patients are at risk for a surgical wound complication such as an
SSI, what to look for, and recognizing the signs and symptoms as early as possible are crucial in
order to implement the appropriate plan of care. SSIs are one of the leading causes of nosocomial
infections impacting patients.
Pre-operative Physical Assessment
An important strategy to prevent surgical wound complications is completion of a detailed pre-
operative assessment to identify potential factors that may impact healing and increase the risk
for an SSI. All factors identified pre-operatively that may affect wound healing must be reported
to all health-care professionals involved in the patient’s post-operative care. 24 If the surgery
required is urgent, pre-operative assessment should focus on the body system immediately
involved.
The American Society of Anesthesiologists has established categories to classify the
patient’s physical status to identify patient-related (endogenous) risk factors for developing an
SSI, with patients in Class III to V being at higher risk:
. Class I: a normally healthy patient with no functional limitations
. Class II: a patient with mild systemic disease that limits activity but is not incapacitating
. Class III: a patient with severe systemic disease that limits activity, but is not incapacitating
. Class IV: a patient with severe systemic disease that is a constant threat to life
. Class V: a moribund patient who is not expected to survive without the operation
The following 12 key risk factors for complications should be identified and addressed wherever
possible:
1. obesity
2. malnutrition
3. smoking
4. hypertension and coronary artery disease
5. pre-existing body site infection5
6. diabetes mellitus (poor glycemic control)27
7. size and virulence of the microbial inoculums28
8. general health and co-morbid disease processes, including medications that affect
integrity of the individual’s host defences28
9. alcohol or substance use
10. physical activity and mobility limitations
11. previous complications with anesthetic and surgeries29
12. advanced age24
Malnourishment impairs healing and increases SSI risk. A body mass index (BMI) that
is above or below the recommended level will place the patient at increased risk of poor
outcomes. Of concern are males with a BMI > 25 kg/m 2 and women with a BMI > 30 kg/m 2, as
this is associated with a five times greater risk of an SSI with subsequent complications than for
non-obese individuals.24,30 This is thought to be related to the increased cardiac output, stroke
volume and poorly oxygenated adipose tissue in obese individuals. 31 When there is fatty tissue
around the neck and diaphragm and laparoscopic gases, breathing is hindered, causing
hemodynamic compromise and further tissue hypoxia.
Surgical patients at risk of possible malnutrition should be screened by a registered dietitian. For
hospitalized patients, the assessment should be conducted using a valid and reliable tool
appropriate to the patient population. Screening should occur at admission or as soon as possible
after admission.
Poor glycemic control and smoking are identified as risk factors for surgical site infections.
Patients with diabetes mellitus (DM) are at double the risk of surgical site infections compared
with their non-diabetic cohorts.33 Elevated post-operative glycemic levels are a significant risk
factor for SSIs and should be aggressively treated. Ata et al. state that post-operative glycemic
control is of more importance than pre-operative levels in relation to SSIs. 34 Hyperglycemia is
associated with surgical mortality and morbidity.35 In a meta-analysis completed by Sorenson, it
was identified that SSIs are two times as likely to occur in smokers than in non-smokers.
Assuming that pre-operative screening can occur, smoking cessation should be encouraged for at
least four weeks prior to surgery. Discussion regarding risk of smoking when surgical
interventions are planned should be part of informed patient consent.
Pre-operative Emotional Assessment
Patient readiness for surgical intervention and emotional health can impact healing and surgical
outcomes. For some, the surgery is a welcome solution to a physically limiting condition. For
other patients, however, the surgery may be unexpected or consented to only as a life-saving
procedure—for example, when a limb is amputated related to diabetes mellitus to prevent the
progression of infection. Here the patient may not be fully prepared for this body alteration. The
emotional results of this will impact the engagement of the patient to participate in their health
and recovery.
For some patients, surgery may mean the end of pain or hope for a cure. It is important
to clearly communicate with the patient and family the intended clinical surgical outcomes and
the potential unexpected results. Many people experience some level of anxiety prior to surgery,
and for people with pre-existing anxiety, it can be exacerbated.
Some methods to reduce anxiety include education and patient handouts, with opportunities to
talk about their concerns, as well as listening to music or reading prior to surgery, or using
relaxation techniques.37 Sedatives are often administered within two hours prior to surgery, which
can help to relieve immediate stress. A com prehensive literature review by Rosenberger et al.
found in five orthopedic studies that patients who were worried, anxious or depressed pre-
operatively were likely to experience a slower recovery, but it did not link these factors to an
increased risk of surgical site infection.38 While we know that psychological stress impacts the
immune system and can negatively impact wound healing, at this time the literature does not
show a direct link to surgical site infections.
Intra-operative Risks
The risk of developing an SSI can be affected by the nature of the intended surgical
procedure; whether or not an SSI develops can depend upon how these factors interact:
1. Length of procedure (greater than 75th percentile of predicted operating time increases
risk) Status of surgery: i.e., clean; clean surgery involving placement of a prosthesis or
implant; clean-contaminated; contaminated; or dirty and infected
2. Type of surgery: Colon surgery carries the highest risk of an SSI, followed by vascular
surgery, cholecystectomy and organ transplant.
3. Method of surgery: Laparoscopic versus open colorectal surgery has a statistically lower
rate of SSI (P < 0.0001), although risk for both types is dependent on the classification
(clean versus dirty) and length of surgery.40 For obese patients, laparoscopic surgery
 reduces SSI rate by 70 to 80% compared with open surgery across general abdominal
surgical procedures.
4. Level of oxygenation of the tissues: Surgical wounds are at high risk of hypoxia, so
preventative measures should include keeping subcutaneous perfusion and oxygenation
optimal (arterial pO2) and preventing conditions that restrict peripheral perfusion, such as
hypovolemia, excessive pain, vaso-constricting drugs and hypothermia.
5. Emergent (vs. elective) surgery
6. Implants (vs. no implants)
7. Use of internal mammary artery grafts (for coronary artery bypass graft)
8. Prolonged ventilation
9. Use of blood products
10. Although it can be assumed that the patient’s stress levels are reduced with medication
during surgery, Nilsson et al. examined the use of relaxing music played in the operating
room and concluded that it may decrease post-operative pain.
Post-operative Risks
Many of the SSI risks following surgery are the same as the pre-operative ones. In addition,
saturated and/or leaking wound dressings allow migration of bacteria to the wound in a rapid
manner.44 Disruption of the sutured or staple incision by vigorous cleansing before it has re-
epithelialized can introduce bacteria below the dermis.
Wound dehiscence can occur around the seventh day post-op 21 and often is linked with exudate
continuing past 48 hours post-op, an SSI, poor glycemic control, malnutrition and obesity. In
addition, mechanical stress on the wound bed from heavy lifting, coughing, vomiting, sneezing
and straining increases the risk of dehiscence.
Patients are also at risk for post-operative infections related to post-operative respiratory and
urinary infections, infections secondary to wound sepsis or medical devices such as indwelling
Foley catheters and intravenous (IV) lines, and diarrhea related to use of antibiotics (e.g.,
Clostridium difficile–associated disease).
Wound dehiscence is a complete or partial disruption of wound closure with or without
evisceration and protrusion of tissue or organs. This is a severe complication that may lead to
immediate surgical intervention, the possibility of repeat dehiscence, a surgical site wound
infection and/or development of incisional hernia formation.
In addition, hematoma or seromas may develop and require intervention. The presence
of hematomas and/or seromas increases pressure, compresses blood vessels, causing wound
ischemia and, if untreated, may cause tissue necrosis. Hematomas can also cause flap necrosis
due to a free-radical-induced cytotoxic mechanism. There is an increased occurrence of
hematoma or seroma in surgical wounds associated with the increased clinical use of
anticoagulants and prophylactic treatments now recommended and implemented for deep vein
thrombosis.
1.2.2 Environmental: Socio-economic, care setting, potential for selfmanagement
Discussion: Poor patient self-efficacy, knowledge required for post-operative wound monitoring
and communication may lead to negative clinical outcomes. In the RNAO’s “Person and Family-
Centred Care Nursing Best Practice Guideline,” it is recommended that to achieve the goal of
“having the person’s proactive and meaningful engagement as an active partner in their health
care, we should listen and seek insight into the whole person to gain an understanding of the
meaning of health to the person and to learn their preferences for care.” 49 A therapeutic
relationship between the person with the surgical wound and the health-care professional is
needed to build a genuine, trusting and respectful partnership.
The RNAO guidelines remind us that we must respect the person as an expert on themselves and
their life, which can be difficult in cases where it is identified that they are making negative
lifestyle choices.49 Families and caregivers also have an important role in the care for and
recovery of people who have had surgery, and if those supports are not part of an individual’s
normal life, the patient may be at increased risk for complications.
The patient’s values, beliefs, culture, ethnicity, spirituality, wishes, interests, life circumstances
(including financial security or worry) and previous health experiences all affect their priorities,
concerns and preferences. The RNAO advises the clinician to “take the time to be present, and
actively listen (without judgment) to hear and learn.”
1.2.3 Systems: Health-care support and communication
Discussion: The National Healthcare Safety Network (NHSN) recommends that SSI surveillance
periods be at least 30 days for superficial incisional, deep incisional and organ/space SSIs. 5 In
addition, 90-day surveillance is required for specific surgeries (prosthesis/implants). The list of
surgical procedures can be found at www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. It is
the responsibility of organizations to reduce harm, improve health care and protect Canadians by
establishing SSI surveillance programs.
With an increasing number of surgical outpatient procedures taking place,29 many SSIs will not
be captured by hospital SSI surveillance programs. Post-discharge surveillance should occur,
with participation of family physicians, nurse practitioners, community home-care agencies,
long-term care facilities, and with a mechanism to report and track recognized signs and
symptoms of SSI, so that outcomes and trends can be reported back to hospitals, surgeons and
health authorities.
Effective surveillance of SSI includes a focus on targeted high-risk and high-volume operative
procedures. Successful SSI surveillance includes “epidemiologically sound infection definitions
and effective surveillance methods, stratification of SSI rates according to risk factors associated
with SSI development, and data feedback.”
In addition, if a surgical wound occurs as a result of an SSI or because it is left open to heal by
secondary intention, there are four main factors that may affect hard-to-heal wounds (see Figure
2). This algorithm outlines the relationships among patient, wound, health-care professional and
resource/treatment-related factors and is intended to support clinicians in recognizing the
complexity of wounds.
The three surgical wound closure goals are as follows:
1. Closed surgical wounds that heal by primary intention are those where the skin edges are
joined together, without any areas of separation, eliminating dead space and minimizing the need
for new tissue formation.59 These wounds generally heal without complications and with minimal
scar formation and do not contain granulation tissue. Exudate from acute surgical wounds is rich
in white blood cells, essential nutrients and growth factors that support the stimulation of
fibroblasts and production of endothelial cells. 60 Re-epithelialization of the uppermost
approximated skin edges normally occurs within 24 to 48 hours and wound closure at two to
three days. Normal practice, however, is to keep sutures or staples intact for seven to 10 days and
sometimes longer at the surgeon’s discretion. Acute surgical wounds heal within an expected
time frame and without complications.
2. Delayed primary closure of a surgical wound may be used to prevent infection in
contaminated surgical wounds. The wound is allowed to remain open for several days before
final closure to ensure all sources of contamination have been removed and/or infection is
resolved.59 Another term for this method is healing by tertiary intention.
3. Surgical wounds that may be dirty or infected heal best by secondary intention, where the
wound is left open and heals when granulation tissue fills the wound from the base up. 59 Failed
primary closure incisions that dehisce or separate are often best left to heal by secondary
intention. It may also be that the wound is deemed “non-healable,” because there is no
opportunity for healing due to co-morbid factors, or that major surgery is required to close the
wound but the person’s health precludes that from happening.
2.1.2 Identify quality-of-life and symptom-control goals.
Discussion: Not all patients look to healing as a goal of care. Pain or tenderness alone can be a
symptom of an SSI, and pain levels need to be consistently addressed to determine if pain
reduction goals are being met.
Intra-operative Strategies
People having surgery are cared for by an operating team that minimizes the transfer of micro-
organisms during the procedure by following best practice in hand hygiene and theatre wear, and
by not moving in and out of the operating area unnecessarily. Staff protocols should include the
removal of all hand jewellery, artificial nails and nail polish before operations.
The skin should be prepared at the surgical site immediately before incision, using an antiseptic
(aqueous or alcohol-based) preparation. Povidone-iodine or chlorhexidine are most suitable.
A paradox occurs with the use of diathermy to create the surgical incision: it increases the risk of
an SSI, even though it is faster than a scalpel and causes less bleeding, both of which
individually, when not associated with diathermy, decrease the risk of an SSI.
If diathermy must be used, antiseptic skin preparations should be allowed to dry by evaporation.
Pooling of alcohol-based solutions should be prevented.9 Studies comparing different closure
techniques, i.e., continuous versus interrupted sutures, have not found a statistically significant
difference in the SSI rate, but using continuous sutures is quicker. 68 Suturing techniques such as
progressive tension closure using a regular or a barbed suture technique in conjunction with
drains for abdominoplasty are being explored as ways to decrease the risk of seromas, 69,70 and
low-tension sutures are more conducive to healing than those applied with too much tension,
which can cause skin injuries on their own. Retention sutures, which are intended to prevent
wound dehiscence in abdominal surgery, can cause increased pain, lacerations and pressure
injuries. A prospective study examining the benefit of prophylactic retention sutures post-
laparotomy concluded there was no significant decrease in incidence of post-operative
evisceration, wound infection and post-operative pain. Adults having surgery under general or
regional anaesthesia must have normothermia maintained before, during (unless active cooling is
part of the procedure) and after surgery. Strategies to maintain patient homeostasis and normal
body functions during the intra-operative and post-operative periods include maintaining a body
temperature of 37°C or 98.6°F, providing supplemental oxygen in the recovery room and
maintaining a hemoglobin saturation rate (SpO2) of 95% during the operation and the immediate
post-operative period.9 Proper hydration during the peri-operative period is warranted, although
further research is required to demonstrate whether supplemental fluids reduce the risk of an SSI.
Safer Healthcare Now recommends the initiation of four key strategies in the peri-operative
phase to reduce an SSI:
1. Perioperative antimicrobial coverage
a. appropriate use of prophylactic antibiotics
b. antiseptic use – bathing, showering
c. decolonization
d. antiseptic-coated suture
2. Appropriate hair removal
3. Maintenance of peri-operative glucose control
4. Peri-operative normothermia
Post-operative Strategies
Depending on the surgery type, post-operative pain can be either nociceptive or neuropathic, or
a combination. Opiates remain key to post-operative pain management, but nonsteroidal anti-
inflammatory agents (NSAIDS) can help to reduce the amount of opiates required in the acute
phase, thus reducing opioid side effects. Post-operative music therapy may reduce the patient’s
anxiety, pain and morphine consumption. Other comfort measures such as non-stick dressings,
warmed solutions and sitz baths for perineal wounds can be tailored to the patient’s needs and
situation but need to be evaluated for effectiveness.10 The patient must be given an opportunity to
discuss their knowledge and beliefs about pain management strategies and provide information
as needed. Their response to the pain management interventions must be consistently reassessed
using the same re-evaluation tool. The frequency of reassessments will be determined by
presence and type of pain, e.g., acute versus persistent, pain intensity, medical condition and
practice setting. Consider prompt post-operative nutritional support to prevent wound
dehiscencecaused by malnutrition.