The definition of a wound is damage to the integrity of biological tissue, including skin, mucous membranes, and organ tissues. Various types of trauma can cause these, and it is critical to ensure wounds are cleaned and appropriately dressed to limit the spread of infection and further injury.
A non-healing surgical wound can occur after surgery when a wound caused by an incision doesn’t heal as expected. This is usually caused by infection — a rare but serious complication.
Causes of poor wound-healing depend on the type and location of the procedure, health condition and other factors. To correctly classify the cleanliness and condition of wounds, the CDC has established classification definitions composed of four classes of wound statuses.
The Centers for Disease Control and Prevention (CDC) estimate approximately 30 million surgical procedures are performed annually in the United States. Advances in technology have afforded patients options such as minimally invasive surgery, commonly known as laparoscopic or arthroscopic surgery, which tend to result in much smaller incisions.
Management of Surgical Wounds
All surgical wounds require a moist environment to support healing. If a dressing change is required within the first 48 hours post-operatively, aseptic technique should be strictly followed. Cleansing of surgical incisions is performed for removal of debris, pathogens, and exudate; it should be done with appropriate pressure utilizing a safe agent to avoid cytotoxicity or mechanical trauma.
Typically, initial surgical dressings are to remain in place for 48–72 hours, and some stay in place for up to seven days. Around post-operation day three, the superficial epidermis of a primarily closed incision line may appear sealed.
Although the tissue layers are not completely healed and are not able to withstand external forces at this time, the epidermis is the first to resurface, or restratify, to begin to form a barrier to pathogens and contaminants.
Incisional Pain Management
Opioid narcotics continue to be the mainstays of post-operative pain management, and combining them with non-steroidal anti-inflammatory drugs (NSAIDs) can significantly reduce the required dosage of opioids for adequate pain relief.
This can serve to reduce the deleterious side effects of opioids, including altered mental status, urinary retention, respiratory depression, and constipation, among others. Complete initial post-operative pain assessment should be comprehensive and include any contraindications for specific methods of pain relief.
Anxiety related to pain, post-operative mobilization and activities of daily living, and often limited recovery time before return to work can actually increase perceived pain.
Distractive measures should not be discounted in the post-operative plan of care for pain management; music therapy can reduce anxiety, reported pain, and opioid use. Frequent reassessments to the pain management plan should be conducted, guided by the type of pain, the patient’s other comorbid conditions, and the care setting.
Risk Factors for Surgical Wound Complications
Two common complications of surgical wounds are infections and wound dehiscence. As such, the following signs should be looked out for in the post-operative wound review: fever, haematoma, seroma, separation of wound edges and purulent discharge from the wound.
Antibiotic therapy should be subsequently tailored once the offending pathogen and its sensitivity have been identified. Debridement of non-viable and infected tissue is another effective method of treating and preventing further extension.
Wounds with equivocal signs do not require immediate antibiotic therapy but should be closely and regularly monitored for any progression of signs.
The CDC classification system is used for surgical wound documentation and involves the patient’s risk for infection and complications.
Any condition that decreases effectiveness of host defenses is a risk factor for developing surgical wound complications. The following list includes conditions that are known to affect surgical wound complication rate:
· Immunocompromised state: diabetes; autoimmune disease such as rheumatoid arthritis or lupus; cancer; long-term corticosteroid therapy; or any patient receiving chemotherapeutic agents or medications that dampen immune response.
· Altered states of perfusion: chronic respiratory conditions such as chronic obstructive pulmonary disease, vascular disorders including peripheral vascular disease, hypertension or hypotension, coagulopathy, smoking
· Functional status: dependent status, generalized debility or immobility predisposing the patient to skin breakdown, affecting self-care capacity, including ability to obtain adequate nutrients.
Conclusion
Optimal management of surgical wounds is an important part of post-operative recovery and health care professionals should monitor the process of acute wound healing, prevent wound complications and treat appropriately if complications arise.
The key elements of post-operative wound management include timely review of the wound, appropriate cleansing and dressing, and early recognition and intervention of wound complications.
