2 Nursing care in surgery

Martina Lepiešová

2.1 Medical and surgical asepsis

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

Purpose
- to minimize the number of risk factors (particularly external factors)
predisposing a patient to an infectious process by following the principles
of medical and surgical asepsis,
- to remove transient and potentially reduce resident flora of the hands by
performing the proper hand washing technique in relation to the
procedures being undertaken,
- to conduct all procedures appropriately from the perspective of infection
prevention,
- to establish a sterile field prior to all invasive surgical procedures.
Collaborative level
- interdependent
All health care professionals, even students, are responsible for maintaining
medical and surgical asepsis and following their principles in direct or
indirect contact with patients with the aim of not contributing to the onset and
spread of infections (hospital acquired infections / cross infections /
nosocomial infections).

Expected patient outcomes

- the risk of onset and spread of infection will be minimized by means of
maintaining medical and surgical asepsis and following their principles by
all health care professionals, including students,
- the sterility of supplies and articles (as needed specifically to for concrete
invasive surgical procedure) will be ensured in the process of preparing
and maintaining a sterile field,
- patient is not exposed to microorganisms,
- patient will not develop signs or symptoms of infection after procedure,
- patient will manifest no signs of infection.

Definitions of key terms

Infection: Infection is invasion by and multiplication of microorganisms in
or on body tissue that have the potential of causing disease; usually results in
an immune response.
Sepsis: Sepsis is referred to as pathologic state resulting from
microorganisms and their byproducts in the bloodstream; an overwhelming
inflammatory and coagulation response can rapidly lead to organ dysfunction
and death.
Asepsis (aseptic technique): Asepsis is defined as the absence of pathogenic
microorganisms; the fundamental methods of asepsis are considered to be the
methods of disinfection and sterilization (physical and chemical methods or
their combination); the aseptic technique must always be performed and
followed within all procedures and all the care provided by health care
professionals.
Medical asepsis: Medical asepsis includes procedures used to reduce the
number of and prevent the spread of microorganisms (e.g. hand hygiene,
barrier techniques, routine environmental cleaning).
Surgical asepsis: Surgical asepsis includes procedures used to eliminate all
microorganisms from an area; is represented by the set of measures
preventing pathogenic microorganisms or their spores from entering or being
transferred to open wounds or exposed body cavities – these measures
prevent contamination of a sterile area by usage of sterile equipment and
supplies.
Antisepsis (antiseptic technique): Antisepsis is the set of measures to
destroy pathogenic microorganisms mainly in the human body’s superficial
areas or in its cavities, whereas the microorganisms have already entered the
wound or body cavity or such possibility is suspected and the spread of
infection has to be avoided; the examples of fundamental methods of
antisepsis are e.g. cleaning the wound by antiseptic solutions, irrigating the
body cavity by antibiotics.

Table 2.1 Medical aseptic practices to break the chain of infection

Element of infection Medical aseptic practices
chain
infectious agent or cleanse contaminated objects; perform cleaning, disinfection
pathogen (disease- and sterilization
producing)
reservoir or source of control sources of body fluids and drainage; perform hand
pathogen growth hygiene; bathe patients with soap and water; change soiled
dressings, dispose of soiled tissues, dressings, linen in
moisture-resistant bags; place used syringes and needles in
puncture-proof containers; keep table surfaces clean and dry,
bottled solutions tightly capped (not opened for prolonged
periods); keep surgical wound drainage tubes and collection
bags/bottles patent, empty and dispose of them according to
institutional policy
portal of exit from if respiratory – avoid talking, coughing, sneezing directly
reservoir over wound or sterile dressing field; cover nose and mouth,
wear masks if suffering respiratory tract infections;
if urine, faeces, emesis, blood – wear disposable gloves when
handling body fluids and substances; wear gown and
eyewear if there is a risk of splashing fluids; handle all
specimens as infectious
mode of transmission perform hand hygiene; use personal set of care items for each
/ spread patient; avoid shaking bed linen / clothes; avoid contact of
soiled item with the uniform; discard any item that has
touched the floor
portal of entry to the if skin and mucosa – keep intact, lubricate skin, offer
host frequent hygiene, turn position; cover wounds as needed,
clean wound sites thoroughly; dispose of used needles as
needed
if urinary – keep all drainage systems closed and intact,
maintain downward flow
host (e.g. susceptible reduce susceptibility to infection – provide adequate
patient) nutrition; ensure adequate rest; promote body defences
against infection; provide immunization
Table 2.2 Principles and practices of surgical asepsis
Principles Practices
all the objects used in sterile appropriate sterilization process; storage for only a
field must be sterile prescribed time – after that unsterile (storage areas
clean, dry, off the floor, away from sinks); check the
packages of sterile materials (intactness, dryness,
expiration date, chemical indicators) – if open,
thorny, punctured or wet – consider it unsterile
sterile objects become use sterile handling forceps / sterile gloved hands; if
unsterile when touched by contact with unsterile objects – discard or re-sterilize
unsterile objects the objects; if questionable sterility – assume it
unsterile
sterile items out of vision or keep in view – never leave the sterile field out of
below the waist level are control, never turn your back on sterile field; keep
considered unsterile sterile gloved hands in view, above the waist and
below neckline; consider sterile draped tables to be
sterile only at surface level
sterile objects can become keep the doors closed, traffic to a minimum; frequent
unsterile by prolonged damp cleaning of the area with detergent germicides;
exposure to airborne hairs clean, short or enclosed to the net / surgical
microorganisms cap; refrain from coughing / sneezing over a sterile
field, keep talking to minimum and wear masks
covering the mouth and nose; if mild upper
respiratory tract infections – wear masks or refrain
from carrying out the procedure; refrain from
reaching over a sterile field unless sterile gloved
hands; refrain from moving unsterile objects over
sterile field
fluids flow in the direction of always hold wet forceps with the tips below the
gravity handles; hold the hands higher than elbows during a
surgical hand wash
moisture passing through use sterile moisture-proof barriers (special barrier
sterile object draws drapes) beneath sterile objects; avoid dampening
microorganisms from sterile field and sterile clothes; replace sterile drapes
unsterile surfaces by capillary if moist
action
the edges of sterile field are 2,5 cm margin at each edge of an opened drape is
considered unsterile considered unsterile; place all objects inside the
edges of sterile field
the skin cannot be sterilized wash the hands prior to procedure, wear sterile
and is considered unsterile gloves / use sterile forceps to handle sterile objects

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

2.1.1 Hand washing procedure

The single most important, quite simple and cheap procedure to prevent and
control transmission of infection is hand hygiene including hand washing
and hand care. The fact is that contact cross infections (hospital acquired
infections) are considered to be one of the highest prevalence and hands of
health care professionals represent the main risk factor in such a case. Hands
contribute to almost every transfer of potential pathogens from one patient to
another, from a contaminated object to the patient or from a staff member to
the patient. With an increased workload, frequent interruptions in providing
care and sometimes limited access to sinks, hand-washing compliance of
health care professionals can be a problem. But we have to realize that as
hand washing is a crucial responsibility for all health care professionals, it
cannot be optional.
Microorganisms found on the skin of hands include two categories:
- Resident microorganisms (normal hand flora) – are usually deep seated
in the epidermis, are not readily removed and do not readily cause
infections. However during surgery or invasive procedures they may enter
deep tissues and establish an infection.
- Transient microorganisms – are not part of normal flora and represent
recent contamination that usually survives for a limited period of time.
They are easily removed by a good hand washing technique. They include
most of the organisms responsible for cross infection e.g. Gram-negative
bacteria (E.coli, Klebsiella, Pseudomonas spp, Salmonella spp.), Staph
aureus, MRSA and viruses e.g. rotaviruses.

Hand washing is a general term used to describe routine hand washing,

antiseptic hand rub or surgical hand asepsis. Thus we distinguish 3
recommended levels of hand washing to ensure its suitable performance for
the tasks being undertaken:
1. Routine hand washing (hand wash / antiseptic hand wash) – is
performed by washing the hands with soap (better not a plain soap or
common cosmetic one, but liquid, pH neutral, disinfecting soap or
antiseptic / antimicrobial detergent in a dispenser) and warm water with
the aim to remove dirt and organic material, dead skin or most transient
microorganisms to make the hands visibly clean.
Examples of its use in healthcare practice are e.g. before coming on duty,
before preparing food, eating or smoking, before and after performing any
bodily functions (e.g. using the toilet, blowing the nose), before and after
any significant direct or indirect contact with the patient (e.g. physical
 examination), before and after routine use of gloves or other personal
protective equipment, after completing the shift, etc.
2. Antiseptic hand disinfection (hygienic hand disinfection / alcohol
hand rub / antiseptic hand rub) – is generally carried out with an
antiseptic hand rub agent / liquid alcohol agent before any aseptic
procedure on the wards and in the areas of isolation with the aim to
remove and kill most transient microorganisms.
Examples of its use are: before and after performance of any invasive
procedure, wound care, urinary catheterisation, insertion of intravenous
catheters, etc. (i.e. in all situations where contact with blood, body fluids
or substances is possible or where microbial contamination is likely to
occur).

Note: In all the situations mentioned if hands are not visibly soiled, use only
an alcohol based rub. If hands are visibly dirty or contaminated, they should
be washed first with soap and water [alcohol-based products have been
found to be more effective than plain soaps or antiseptic soaps; moreover
those containing emollients have caused substantially less skin irritation and
dryness than plain soaps or antimicrobial soaps tested].

Proper hand hygiene (hand washing and hand rub procedures) together with
the basic principles of hand care are introduced in table 2.3 and in figure
2.1.

Table 2.3 Hand hygiene – hand care and hand washing procedure
Hand care – checklist
- keep the nails short, don’t wear
nail polish (even a transparent
one) or artificial nails
- don’t wear ridged / stoned rings
(wedding ring is questionable –
refer to the institutional policy)
- remove wrist watches and all
jewellery
- roll up / remove long sleeved
clothes
- maintain skin intact as far as
possible
- cover cuts and abrasions with an
impermeable waterproof plaster
- don’t use communal pots of hand
Sequence of hand washing procedure (hand
washing / hand rub
- wet the hands and wrists under running
warm water
- take a dose of soap / hand wash into a
cupped hand – always operate the
dispenser’s application with the elbow to
push the detergent
- wash hands for 40 – 60 seconds thoroughly
on all the surfaces of hands by six basic
movements (Figure 2.1) without adding
more water
- keep hands and forearms lower than elbows
during washing to facilitate removal of
microorganisms
- rinse hands and wrists thoroughly under
running water, keeping hands down and
elbow up
 cream (better individual-use hand - don’t turn the taps off with clean hands – if
creams, creams produced elbow or foot control isn’t available, use a
specifically for use after a paper towel to touch and operate the taps
concrete antiseptic alcohol agent) - dry the hands properly with a disposable
- always wear disposable gloves paper towel or a fresh portion of a roller
when handling blood, body fluids towel (no need to use several sheets of
or substances (but never regard disposable paper)
gloves to be a substitute for hand - rub the dose of liquid alcohol agent /
washing!) antiseptic hand rub agent (3 ml by one
push) into the skin of dry hands following
all six basic movements for at least 30
seconds
Note: An alternative method of hand disinfection as already described is the use of
alcohol gels. They are formulated for use without water and are particularly useful in
areas where a hand-washing basin is not readily available, or when return to a hand-
washing basin is impractical e.g. during a ward round, in between bed making, during
a dressing procedure, etc.

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

1. Palm to palm 2. Right palm over left 3. Palm to palm, fingers

dorsum and left palm interlaced
over right dorsum

4. Backs of fingers to 5. Rotational rubbing of 6. Rotational rubbing,

opposing palms with right thumb clasped in backwards and forwards
fingers interlocked left palm and vice with clasped fingers of
versa right hand in left palm
and vice versa

3. Surgical hand hygiene (surgical disinfection, surgical hand antisepsis,

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

Generally the efficacy of hand washing depends on the application of an

adequate volume of a suitable agent with a good technique covering all
surfaces of the hands at the right time for the correct duration of time, proper
drying of the hands already washed and finally ensuring non-touch technique
(particularly in surgical disinfection).

2.1.2 Establishing and maintaining a sterile field

Sterile field is a microorganism-free area (including free of spores)
established by nurses prior to all invasive surgical procedures (sterile aseptic
procedures, operating room procedures) using a sterile kit or tray, a work
surface draped with a sterile towel or wrapper, or a table covered with a large
sterile drape. Sterile drapes establish a sterile field around a treatment site,
e.g. a surgical incision, venipuncture site, site for introduction of urinary
catheter. Once the field is established, sterile supplies (instruments, dressing
materials, antiseptic solutions, etc.) can be placed on it.

Equipment
- waist-high table,
- package containing a sterile drape (or sterile kit to be used as a sterile
field),
- sterile equipment and supplies as needed specifically for the procedure
(e.g. sterile surgical instruments – plain dissecting forceps / plain thumb
forceps / tissue forceps / pincette, surgical scissors, surgical spoons,
haemostat / artery forceps / forceps / pean, suture forceps, scalpels, suture
material, sterile dressing material, antiseptic solutions, etc.),
- disposable cap and mask (and/or protective eyewear), sterile gloves,
sterile gown.

Assessment
1. Verify that the procedure requires a surgical aseptic technique.
2. Anticipate the number and variety of supplies needed for the procedure
[failure to have necessary supplies causes you to leave a sterile field,
increasing the risk of contamination].
3. Assess patient’s comfort, oxygen requirements and elimination needs
before preparing the procedure [certain procedures may last a long time].
4. Confirm the sterility of packages
- ensure that package is clean, dry, intact (no punctures, tears or
discolouration), check for sterilization expiration dates, sterilization
indicator [if moist, or there are any indications it has been previously
opened, consider it contaminated and discard it].

Implementation
5. Complete all other priority tasks before beginning the procedure [sterile
field should be prepared as close as possible to the time of its use].
6. Position patient comfortably for a specific procedure with the help of
assistive personnel.
7. Explain the procedure to the patient (purpose, process, importance of
sterile technique) [enables patient to cooperate and eliminates need to
talk during procedure, increasing risk of contamination].
8. Apply cap, mask, and/or protective eyewear and/or gown as needed due to
institutional policy.
9. Perform hand hygiene thoroughly (hand washing and alcohol hand rub).
10. Open the package.
10a) To open a wrapped package:
- place the package in the centre of work area (clean, dry, flat work surface
above waist level) so that the top flap of the wrapper opens away from
you [position like this prevents reaching over the exposed sterile content],
- by reaching around the package (not over!), pinch the first flap on the
outside of the wrapper between the thumb and index finger and open the
flap [touching the outside of the wrapper maintains the sterility of the
inside],
- do the same with side flaps, using the right hand for right flap and vice
versa [using both hands avoids reaching over the sterile contents],
- pull the fourth flap toward you, make sure not to touch the uniform by the
flap.
Note: To open a wrapped package while holding it, hold the package in one
hand (non-dominant) with the top flap of the wrapper opening away from you
and by using the other, dominant hand, open the package pulling the corners
of the flaps.
10b) To open commercially prepared packages:
- if the package has an unsealed corner, hold the package in one hand and
open it by pulling the flap back with the other hand,
- if the package has a partially sealed edge, grasp both sides of the edge,
one with each hand, and gently open by pulling apart.
11. Establish a sterile field by using a drape
- open the package containing the drape, apply sterile gloves (this is
optional according to institutional policy), with dominant hand pluck the
corner of the drape that is folded back on the top and lift the drape out
from the cover allowing it to open freely without touching any objects,
- with the other hand, pick up another corner of the drape, holding it well
away from yourself,
- lay the drape on a clean and dry surface, placing the freely hanging
bottom half farthest from you and then place top half of drape on work
surface [to prevent leaning over the sterile field and contaminating it].
12. Add necessary sterile supplies
- open the package of the supply while holding outside wrapper in non-
dominant hand,
- secure wrapper edges by peeling the wrapper over non-dominant hand,
- hold the package approx. 15 cm above the field and allow the contents to
drop onto the field (in bigger packages with bigger supplies, gently place
the sterile supply from opened package on the sterile field by approaching
from an angle – never reach arms over sterile field).
13. Pour sterile solutions
- remove seal and cup from bottle in upward motion, gently pour solution to
the sterile container (metal / plastic / porcelain bowl or cup) with the
solution bottle held away from sterile field and the bottle lip approx. 10 –
15 cm above the container.
14. Use sterile forceps (handling forceps / transfer forceps) to handle certain
sterile supplies, e.g. to move sterile article from one place to another
- keep the tips of wet forceps (if stored in wet method or made wet during
its use) lower than the handles at all times unless sterile gloved hands
 [prevention of flowing the liquids from the tips to the handles and later
back to tips – handles are unsterile if held by the hands],
- hold sterile forceps always above waist level, within sight,
- when using forceps to lift sterile supplies out of the package, be sure they
don’t touch the edges or outside of the wrapper,
- don’t permit moist forceps to touch the sterile field if the surface under
sterile field is unsterile and moisture-proof drape is not used as a barrier.

Complications
- any break in sterile technique (e.g. sterile field has come into contact with
contaminated object, liquids splash onto drape) may lead to contamination
of sterile field thus requiring setting up a new sterile field.

Documentation
- no recording or reporting is required for this set of skills,
- record sterile procedure performed including assessment of patient’s
status prior to and its evaluation during and after the procedure.

2.1.3 Donning and removing sterile gloves

Gloves together with the other personal protective equipment (PPE) such
as gowns, aprons, eye or facial protectors (glasses, goggles, facial shields),
caps and masks, provide a barrier between the source of infection and the
host. Gloves help prevent transmission of pathogens by direct or indirect
contact. Their use doesn’t negate the need for safe working practices or hand
washing – the gloves should be used as an addition to hand washing. There
are 3 types of gloves (mostly latex, i.e. natural rubber gloves) worn in health
care facilities according to the tasks being undertaken:
1. General-purpose utility gloves – used for manual decontamination of
instruments or equipment used, cleaning and cleansing the areas.
2. Disposable gloves (non-sterile examination gloves) – used when
contamination of hands is anticipated or whenever there is a risk of direct
or indirect contact with blood, body fluids and body substances, mucous
membranes or non-intact skin (e.g. specimen collection), except the
performance of sterile procedures, or procedures involving normally
sterile body cavities.
3. Sterile gloves – used for all invasive surgical procedures (sterile
procedures, involving normally sterile body areas), e.g. inserting urinary
catheters, changing dressings on central i.v. catheters, cleaning open
 wounds. Sterile gloves may be donned by the open method (used outside
the operating room) and closed method (requires nurse to wear a sterile
gown).

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

Assessment
1. Verify that the procedure requires the use of sterile gloves – consult
institutional policy, consider patient’s risk of infection.
2. Assess patient for the risk factors of he or she being predisposed to latex
allergy reaction (history of asthma, contact dermatitis, rhinitis, food
allergies, previous adverse reactions during surgery or dental procedure,
previous reaction to latex products – adhesive tape, face mask, bandage,
elastic underwear, i.v. tubing, condom, rubber gloves, ostomy bag, etc.) –
choose the correct material.
3. Confirm the sterility of the package.

Implementation
4. Perform hand hygiene thoroughly (hand washing and alcohol hand rub).
5. Donning sterile gloves (Figure 2.2)
- remove the inner glove package from the outer package, place the inner
package of gloves on a clean, dry, flat surface at waist level,
- open inner package by plucking the flaps and folded tabs so that the
fingers do not touch the inner surfaces,
- identify right and left glove (each having a cuff approx. 5 cm wide),
- non dominant hand first: with thumb and first two fingers of your non-
dominant hand, grasp the glove for the dominant hand by the edge of
glove cuff touching only the inside of cuff [inner surface of cuff will lie
against skin and thus is not sterile], insert the dominant hand into the
glove and carefully pull the glove on while keeping the thumb of inserted
 hand against the palm [thus the thumb is less likely to contaminate the
outside of the glove] leaving cuff and being sure cuff doesn’t roll up wrist,
- with gloved dominant hand pick up the other glove, inserting the gloved
fingers under the cuff and holding the gloved thumb close to the gloved
palm [prevention of accidental contamination of the glove by the bare
hand] and pull on the second glove carefully keeping the thumb of
dominant hand as far as possible from the palm (abducted back),
- after second glove on, adjust each glove so that it fits smoothly e.g. by
interlocking the hands together above the waist level (the cuffs usually fall
down – if not, carefully pull cuffs up by sliding the fingers under the cuffs
touching only sterile sides).

Figure 2.2 Sequence of donning sterile gloves

6. Removing used gloves

- remove them by turning them inside out and discard,
- perform hand hygiene thoroughly (hand washing to remove the powder
from hands and alcohol hand rub).

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

Documentation
- no recording or reporting is required for application of gloves; record and
report possible latex allergy reaction – patient’s response, vital signs,
treatment applied and reaction to it,
- record sterile procedure performed including assessment of patient’s
status prior to and its evaluation during and after the procedure.
Test your knowledge
1. What is the difference between medical and surgical asepsis?
2. Summarize the principles and rule of hand care except hand washing.
3. When to use different types of hand washing?
4. What is the time exposure to antiseptic hand rub agent in hygienic hand
disinfection and in surgical hand disinfection?
5. Name 3 examples of principles of surgical asepsis and practices for each
principle.
6. Describe and explain how to hold wet sterile handling forceps during
establishing a sterile field while adding necessary sterile supplies.
7. Name risk factors predisposing the patient to latex allergy reaction.

Extras for further study

- surgical dressing cart (dressing trolley),
- surgical instruments,
- operation tract,
- minor surgical procedures.

2.2 Wound care

To manage acute and chronic wounds as a major component of nursing care

in surgery it is crucial for nurses to understand the physiology of wound
healing, factors affecting it and specific measures to promote it.

Purpose
- to identify types of wounds and appropriate treatment options for certain
types,
- to assess and report all the characteristics of a wound properly including
wound healing process,
- to promote wound healing and minimize the risk of complications,
- to perform specific procedures of wound care correctly (e.g. removing
soiled dressing, wound cleansing (cleaning, irrigation), applying a sterile
dressing, suture removal, care of a wound-drainage system),
- to prevent infection.

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

Expected patient outcomes

- patient will display normal wound healing / stabilization if healing isn’t
possible (wound is clean, free of drainage and inflammation / drainage is
decreased in amount and type, skin integrity is maintained),
- patient is not exposed to microorganisms / will not develop signs of
surgical wound infection.

Definitions of key terms

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

Table 2.4 Wound classification

Type Description and characteristics
 according to cause – how wounds are acquired
incision sharp instrument (scalpel, knife) – open, painful wound
contusion blunt instrument – bruised skin, closed wound
abrasion falls / intentional to remove pockmarks – surface scrape
puncture sharp instrument – penetration of skin and underlying tissues
laceration accidents (machinery) – tissues torn apart, edges jagged
penetrating accidents (bullet, metal fragments) – penetration of skin and
wound underlying tissues
according to likelihood and degree of contamination
clean surgical, uninfected, not entering the respiratory, alimentary, genital
or urinary tracts (primary closed wounds, sutured by primary suture
or drained with closed drainage)
clean- surgical, entering the respiratory, alimentary, genital or urinary
contaminated tracts, but no evidence of infection
contaminated fresh, open, accidental or surgical with the evidence of inflammation
dirty old, accidental wounds containing dead tissue, wounds with
evidence of clinical infection (purulent drainage etc.)
according to depth (the tissue layers involved in the wound)
partial- confined to the skin (dermis and epidermis); healed by regeneration
thickness
full-thickness involving dermis, epidermis, subcutaneous tissue and possibly
muscle and bone; require connective tissue repair
according to course and duration of wounds
acute developed in healthy tissue, e.g. surgical wounds, abrasions,
incisions, 1st and 2nd degree burns
chronic developed in tissue that is trophically impaired / are acquired by
secondary dehiscence, e.g. ulcers (venous, arterial, diabetic, pressure
ulcers, malign wounds, radiation burns), 3rd degree burns
classification of open / secondary intention healing wounds according to the
colour of wound by WCS (Woundcare Consultant Society); Marion
Laboratories, Inc.
red (or pink) clean, granulating (new healthy tissue) and epithelializing wound,
healing well
red or pink granulation tissue
the goal of wound management is to protect red wounds and cover
them by selection of transparent film or hydrocolloid dressing
maintaining clean and slightly moist wound environment and
minimize damage to healing tissue (i.e. gentle cleansing, avoiding
use of dry gauze or wet-to-dry saline dressings, changing the
dressing as infrequently as possible)
yellow wound coated by dead subcutaneous fat tissue, liquid or semi-liquid
slough (grey necrotic slough) often accompanied by purulent
drainage
the goal of wound management is to cleanse yellow wounds (to
absorb drainage and remove non-viable tissue) by selection of
moisture-retentive dressings enhancing debridement (wet-to-wet or
wet-to-dry dressing, impregnated non-adherent dressings,
hydrocolloids, hydrogels, alginates, other exudates absorbers),
wound irrigations
black covered with black eschar (representing full-thickness tissue
 destruction) – a thick leathery necrotic devitalized tissue with no
proper circulation thus providing excellent medium for bacterial
growth
require debridement (removal of infected and necrotic material)
the goal of wound management is to debride black wounds by
chemical enzymes (autolytic debridement with the use of occlusive
or semiocclusive dressings), mechanical debridement (surgical
necrectomy)

Table 2.5 Phases of wound healing

Inflammatory essential for healing, initiated immediately after injury, lasts 3-4
phase days
haemostasis (the cessation of bleeding by means of vasoconstriction
of large blood vessels in the affected area, retraction of injured
vessels, deposition of fibrin and formation of blood clots) – scab is
formed on the wound surface, a thin wall of epithelial cells
develops across the wound
inflammatory response – increased blood supply to the wound to
bring substances and nutrient needed in healing process – localised
redness and oedema
cellular responses – cell migration (leukocytes – neutrophils,
macrophages) – phagocytosis, angiogenesis factor (AGF) secretion
Proliferative extends from day 3-4 to about day 21 after injury
phase synthesis of collagen (whitish protein substance adding strength to
the wound) – raised “healing ridge” appears under the intact suture
line (can be felt along a healing wound)
development of granulation tissue – translucent red colour, fragile
tissue, risky for bleeding
epithelialization – epithelial cells migrate to matured granulation
tissue proliferating over this connective tissue base to fill the wound
– pink scar
Maturation from day 21 to 1-2 years after injury
(remodelling) continue in the synthesis of collagen – scar becomes a thin, less
phase elastic, white line

Table 2.6 Types of healing

Primary intention e.g. in clean surgical incisions in which wound edges were
healing (first intention pulled together with sutures, staples or adhesive tapes;
healing, per primam means the tissue surfaces have been approximated, closed
intentionem) and there is minimal or no tissue loss (minimal granulation
tissue and scaring occurs); healing occurs by connective
tissue deposition
Secondary intention e.g. in open extensive wounds with considerable tissue loss
healing (per secundam (such as pressure ulcers) in which the edges cannot be
intentionem) approximated (there is some gap between edges); in such
healing the repair time is longer as granulation tissue
gradually fills in the area of the wound with scar tissue, the
scaring is greater, the surface closure is thicker and the
susceptibility to infection is greater due to the slowness of
the process; healing occurs by granulation tissue formation
and contraction of wound edges
Tertiary intention indicated when there is a reason to delay suturing a wound
healing (delayed or (because of poor circulation in the area, or to allow oedema
secondary closure, per or infection to diminish) to the time after the initial stage of
tertiam intentionem) deposition of granulation tissue (usually for 3 to 5 days),
e.g. healing in opened abdomen

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

2.2.1 Cleaning a wound and applying a sterile dressing

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

Table 2.7 Basic principles of wound cleansing

- choice of solution is the physician’s
preference
- solutions used are always sterile,
warmed to body temperature when
possible
- use a sterile technique for surgical
wounds and a clean technique for
chronic wounds
- cleanse always from “clean to dirty” area - various methods of cleansing the
(difficult to differentiate) – the suture
line or any area being cleansed is
considered the “least contaminated” and
surrounding skin surfaces are considered
“contaminated”
- clean the wound during every dressing
change if contaminated or exudate if
excessive, otherwise avoid repeated
unnecessary cleaning
- prefer irrigating the wounds by a stream
of solution against mechanical cleaning
- use a new sterile gauze swab for each
stroke while cleaning (do not use
cotton wool balls)
- suture line is always cleansed first /
the drain site is cleansed using
circular strokes (commonly used
methods to clean a surgical wound
and drain site are in figure 2.3)
wounds are described – variations
include the following (strong need for
further research):
- holding cleaning swabs with
forceps versus sterile gloved hands
- cleaning from wound in outward
direction versus cleaning in any
direction unless there are signs of
infection
- cleaning the surrounding skin first
and then the wound versus cleaning
- maintain wound moisture – avoid drying the wound first and then the skin
it after cleaning - not cleaning the wound at all if it
appears to be clean

Figure 2.3 Methods of cleaning surgical wound and a drain site

clean it from top to bottom
start at the centre moving
toward one end, then start at
the centre again and work
toward the other end,
continue with other
movements in straight lines
moving away from the
suture line
start in the area
immediately next to the
drain (with each new
swab attempt to clean a
little further out from
the drain)

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

Table 2.8 Basic principles of securing the wound dressing

- place the tape so that the dressing cannot be folded back (strips of tape at the ends
of dressing and across the middle), ensure the tape is long and wide enough (Figure
2.4)
- place the tape in the opposite direction from the body action (across a joint, not
lengthwise)
- place the tape at 90 degree angle to suture line if possible (so that wound edges are
pulled together)
- when removing the original adhesive tape, always pull the tape toward the wound
to prevent strain on the sutures and to reduce the risk of wound dehiscence (pull the
tape gently but firmly while holding down the skin with non-dominant hand to
provide counter-traction); if necessary to loosen the tape particularly on hairy
surfaces, moist it with some solvent (e.g. acetone)

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

Equipment
- disposable / sterile gloves [disposable to protect yourself during removal
of soiled dressing; sterile to examine the depth of a wound / to hold sterile
dressing supplies], other PPE – mask, protective eyewear, gown
[optional],
- sterile handling forceps in a sterile cylinder / jar [to handle sterile
instruments or sterile dressing supplies],
- sterile cassette with sterile surgical instruments (e.g. forceps to hold
cleansing swab; probe to assess the wound depth; surgical spoon / scalpel
for mechanical debridement / surgical necrectomy; suture forceps to make
sutures; surgical scissors to cut the sutures / sterile dressings / to shorten
the drains, etc.),
- sterile cleansing solutions and irrigation delivery system if irrigation is to
be performed (sterile pink needle, sterile syringe, sterile catheter) [to
withdraw solution from a sterile bottle and apply it to/on the wound],
- dressing supplies – sterile gauze swabs, sterile gauze squares in sterile
packages (paper wrapper – Lucasteric sac / paper-folic wrapper / bowls /
cassettes) or commercially prepared sterile packages of synthetic modern
dressings,
- clean bandage scissors [to cut the packages, to cut the bandages],
- adhesive tapes / bandages of proper width / binders [to secure the new
dressing],
- clean kidney dish / collection basin and disposable waterproof biohazard
bag,
- folded paper towels or extra moisture-proof underpad [to protect bed /
patient’s personal clothes / pyjama],
- extra bath blanket [to cover patient’s intimate parts when needed],
- additional supplies required (e.g. extra absorbent dressings – surgipads,
folded cotton wool, ordered ointments, powders, etc.).

Assessment
1. Review physician’s orders concerning wound cleansing / any other wound
care procedure (increased frequency of cleansing, specific supplies
required, what to report, etc.).
2. Assess recent recording of any characteristics related to patient’s wound
to get prepared for the procedure and to identify the changes in wound
condition after removal of soiled dressing (extent of integrity of skin
impairment; wound location; wound size in length, width, depth; signs of
infection – e.g. elevation of body temperature, wound odour, wound
colour; wound drainage as for amount, colour, consistency, type – serous,
sanguineous, serosanguineous, purulent; stage of wound healing; wound
dressing – if clean, dry, evidence of bleeding, profuse drainage; identify if
patient is at risk of wound healing problems).
3. Assess patient’s history of allergies to antiseptic solutions, tapes or
dressing materials, assess the risk factors predisposing for latex allergy
reaction – modify the selection of supplies to use the correct material.
4. Assess patient’s comfort level or pain (on numeric scale of 0 to 10),
symptoms of anxiety, elimination needs before preparing the procedure
[discomfort may be related directly to wound, anxiety to anticipation of
unknown procedure; certain procedures may last a long time].
5. Confirm the sterility of all packages and sterile supplies.

Implementation
6. Explain the procedure to the patient (purpose, process, importance of
sterile/clean technique) [to reduce anxiety, to enable patient to
cooperate].
7. If necessary, apply premedication (prescribed analgesic) 30 to 45 minutes
prior to the procedure [to ensure patient’s comfort positioning, to enable
patient to cooperate].
8. Position patient comfortably for specific wound care procedure, expose
the wound and place extra towels and kidney dish close to the wound area
to protect bedding and collect any possible exiting fluids [to permit
gravitational flow of possible excessive drainage or irrigating solution
into this collection basin].
9. Close the room door / bed curtains, use extra bath blanket to cover the
patient if needed.
10. Prepare a waterproof bag for disposal of soiled dressings within reach,
make cuff on it.
11. Perform hand hygiene thoroughly (hand washing and alcohol hand rub).
12. Apply disposable gloves and/or other PPE as needed due to institutional
policy.
13. Remove soiled dressings appropriately
- untie binders or bandages / cut them with bandage scissors (but never
directly above the wound) / remove adhesive tapes; remove all the
dressing layers always with underside away from patient’s face [not to
make him/her upset], taking care not to dislodge any drains while
removing the under layer [if gauze sticks to drain, support the drain with
one hand while removing the dressing; if dressing material adheres to any
tissue during removal, soak it with normal saline],
- assess amount, type and odour of wound drainage based on the soiled
dressings,
- discard the soiled dressings including gloves used in waterproof bag.
14. Wash the hands.
15. Assess the characteristics of wound / wound healing [if assessing includes
touching the wound, e.g. examining the depth of wound, put on sterile
gloves].
16. Describe the appearance of the wound and indicators of wound healing to
the patient.
17. Set up sterile supplies (using surgical aseptic technique)
- by using handling forceps draw up the forceps / any other instrument from
the cassette always catching the middle part of an instrument, pass it to the
 physician by the handles or carefully put it into sterile jar to be offered
later [don’t contaminate the cassette cover or instrument’s tips; close the
cassette as soon as possible],
- cut the sterile package of gauze swabs with bandage scissors (usually
paper wrapper), open the package carefully [don’t touch the inside of the
wrapper], draw the swab by handling forceps and pass it to the physician
to be carefully caught by the physician’s forceps [avoid touching the
instruments],
- open the sterile cleaning solution and pour it over the sterile swab held by
the physician’s forceps to moisten the swab [be aware not to touch the
swab keeping the bottle lip approx. 10 cm above the swab; physician
should hold the swab approx. 10-15 cm over the kidney dish as well],
- when ordered, prepare the irrigation delivery system by filling the sterile
syringe with irrigation solution and/or attaching the sterile catheter,
18. Cleanse the wound by mechanical cleaning or irrigation
- if indicated to take a specimen from the wound, always obtain it before
cleansing it,
- clean the wound using the forceps and gauze swabs moistened by cleaning
solution following the principles of wound cleansing [keep the forceps
tips lower than the handles all the time, use separate swab for each
stroke, discard each swab used],
- if a drain is present, clean it after the incision [the main surgical incision
is considered cleaner because of considerable drainage around the
drain], support and hold the drain erect while cleaning around it,
- if irrigating wound, flush it using slow continuous pressure, ensuring
gravitational flow of irrigating solution through the wound into this
collection basin,
- dry the surrounding skin with dry gauze swabs as required, if needed
clean up the skin from tape marks with some solvent.
19. Apply powders / ointments as ordered
- shake powders directly onto a wound / use sterile applicators to apply
ointments [sterile tongue blades / sterile blunt instruments such as
forceps, surgical probe]
20. Apply dressings to the drain site and the incision
- apply all the layers of dressings as needed [primary layer is usually
applied moistened with cleaning solution, secondary is usually dry or
absorbent if needed; manipulate with forceps using surgical aseptic
 technique; if necessary, use forceps to feed the gauze square gradually
into deep depressed wound areas – undermining, tunneling],
- if a drain is present, place a pre-cut sterile gauze square [or cut the sterile
square with sterile surgical scissors] nearly around the drain,
- secure the dressings as needed.
21. Remove PPE, assist the patient into a comfortable position, dispose
of equipment and soiled supplies and perform thoroughly hand hygiene.
22. Inspect the wound dressing periodically to determine patient’s
response to wound care procedure (at least every shift).

Complications
- wound dressing is dry and too adherent when removed,
- appearance of bleeding or serosanguineous drainage, retained fluid or
debris, increased pain or discomfort in the patient, signs of inflammation,
- increase of wound drainage (more than dressing can absorb),
- irritation of the skin around the wound (red, macerated or excoriated),
- suture line opening extends or a drain is removed accidentally,
- dressing doesn’t stay in place.

Documentation
- record the procedure performed (e.g. type of solution used, type and
amount of dressings applied, frequency of dressing change) including
wound assessment before and after the procedure, patient’s tolerance of
the procedure, patient’s status prior to and its evaluation during and after
the procedure,
- immediately report to the physician (if he or she isn’t present) any
evidence of fresh bleeding, sharp increase in pain, accidental removal of a
drain, evidence of wound dehiscence or evisceration (particularly in the
wounds after removal of sutures), signs of shock,
- record and report possible allergy reaction – the cause, patient’s response,
vital signs, treatment applied and reaction to it.

Test your knowledge

1. Describe selected types of wounds according to their causes – laceration,
incision, abrasion.
2. Does the classification of wounds according to their colour (e.g. yellow,
red, black) refer to primary intention healing wounds or secondary
intention healing wounds?
3. Describe and explain the phases of wound healing.
4. What type of gloves would you wear to remove a soiled wound dressing?
5. Would you use gloves to assess the characteristics of a wound or wound
healing? If yes, when and what type of gloves?
6. How would you cleanse a surgical wound by mechanical cleaning?
Explain procedure, equipment, principles.

Extras for further study

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

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