The Art of Wound Closure & Caring for Postoperative Wounds

Transcription

1 The Art of Wound Closure & Caring for Postoperative Wounds By: Megan Stewart, MD and Erika Probst, RN 1

2 Welcome Welcome to the Medline University course, The Art of Wound Closure & Caring for Postoperative Wounds. This course was created by Megan Stewart, MD and Erika Probst, RN. Megan Stewart is a physician with training in General Surgery. She received her MD Degree from the University of Kentucky College of Medicine, and trained in General Surgery in Grand Rapids, MI. Erika Probst received her Bachelor of Science in Nursing from The University of Portland and her Master of Science in Nursing from Walden University. She has over 15 years of maternal child nursing experience with her certification in maternal newborn nursing. Objectives The objectives for this course are as follows: 1. Provide a background understanding of surgical wound closure. 2. Review the various types of suture that can be used in wound closure, as well as commonly used suturing techniques for wound closure. 3. Discuss surgical glue: how it was developed and the progression of its use. 4. Explain how to care for different surgical wounds. 5. Discuss general discharge teaching for patients with surgical wounds. Module One This module will start with a brief introduction discussing the different types of surgical wound closure and tools for wound closure. Specific suture characteristics and classifications as well as common suturing techniques will also be discussed in this module. Postoperative Wounds In order to understand postoperative wound care, it is important to understand the different types of wound closure. Primary closure, also known as healing by primary intention, is when the surgical wound is fully closed in the operating room, either with staples, suture, or surgical glue. Secondary closure, or healing by secondary intention, is when the wound edges are not initially approximated in the operating room and granulation tissue gradually fills in the wound defect, healing the wound. Delayed primary closure, also known as healing by tertiary intention, is when the surgical wound is initially left open following the surgery, but is closed after a few days of observation if no infection is present. Both secondary closure and delayed primary closure are used when the wound is thought to be contaminated leading to an increased risk of infection. Secondary closure and delayed primary closure allow the wound to drain. (Meyers, 2008) Types of Wound Closure In order to understand postoperative wound care, it is important to understand the different types of wound closure. Primary closure, also known as healing by primary intention, is when the surgical wound is fully closed in the operating room, either with staples, suture, or surgical glue. Secondary closure, or healing by secondary intention, is when the wound edges are not initially approximated in the operating room and granulation tissue gradually fills in the wound defect, healing the wound. 2

3 Delayed primary closure, also known as healing by tertiary intention, is when the surgical wound is initially left open following the surgery, but is closed after a few days of observation if no infection is present. Both secondary closure and delayed primary closure are used when the wound is thought to be contaminated leading to an increased risk of infection. Secondary closure and delayed primary closure allow the wound to drain. (Meyers, 2008) Goals of Wound Closure Most surgical wounds are closed primarily. There are several goals of primary wound closure that need to be discussed in order to understand how to care for these wounds. These include closing the dead space of the wound, approximating skin for an aesthetically pleasing result, providing support to the wound during healing, achieving hemostasis, and reducing infection rates. (Szarmach et. al., 2003) Methods for Wound Closure Sutures are the traditional method for wound closure. Staples have become common for closure of the skin during certain operative procedures as well, and may be used in addition to sutures. Additionally, surgical glues have been developed that can act as adhesives both within the body and on the skin for wound closure. This course will discuss these methods for wound closure and how they affect postoperative wound care. Module One will focus on sutures. Important Suture Characteristics There are several characteristics sutures should have. First of all, it is important for sutures to be sterile in order to decrease the risk of infection. The suture should be easy to handle and suture knots should hold firmly when tied. Suture material should cause minimal tissue injury and tissue reaction. (Szarmach et. al., 2003) Suture Types There are many types of suture available for wound closure. The type of suture used affects how the wound heals. Factors affecting which type of suture should be used for a given wound include the anatomic location of the wound, the thickness of the skin, and the amount of tension on the wound. (Adams et.al., 2003) Suture Classifications Sutures can be classified based on various characteristics. It is important to understand the classifications of different types of suture materials, as these affect which type of suture should be used for a particular wound. The classification of a suture type can define whether a wound will be more likely to become infected or come apart. These classifications include natural versus synthetic, monofilament versus multifilament, and absorbable versus nonabsorbable. The next slides will discuss these characteristics in more detail. (Ratner, 1994) Synthetic vs Natural Synthetic sutures are composed of artificial collagen polymers, while natural sutures are derived from the collagen of mammal intestines. Natural sutures tend to lead to an increased immune response, and, therefore, inflammatory reactions. However, synthetic sutures can also lead to local inflammation (Ratner, 1994). Examples of natural sutures include catgut, chromic gut, and silk. Despite its name, catgut suture does not come from cats, but is actually made from twisting fibers from the collagen of sheep, cattle, or goat intestines. Chromic gut is plain gut which has been treated with chromium salts; these salts decrease tissue reactivity and increase the time of absorption. There are many different synthetic suture materials, including Monocryl, PDS, Vicryl, Nylon, Ethibond, and Prolene. (Medscape, 2015). 3

4 Monofilament vs Multifilament Monofilament sutures are made of a single strand of material. Multifilament sutures are composed of many filaments that are either twisted or braided together. Monofilament sutures tend to be more resistant to pathogenic organisms and also pass through tissue with less resistance than multifilament sutures, but can be more prone to crushing or crimping (Ratner, 1994). Multifilament sutures often have greater tensile strength than monofilament sutures. However, multifilament sutures also tend to absorb fluid more easily, which can increase the risk of infection and surgical wound dehiscence (Ratner, 1994). Surgical wound dehiscence is splitting open or rupture of a surgical incision that had been closed after surgery (Sandy-Hodgetts, K., Carville, K., & Leslie, G. D., 2015). Examples of monofilament sutures include Monocryl, PDS, Nylon, and Prolene; examples of multifilament sutures include silk, Vicryl, Ethibond, and chromic gut. (Medscape, 2015). Absorbable vs Non-absorbable As the name implies, absorbable sutures provide support to the wound for a period of time until the wound can heal and support itself. Ultimately the suture material is absorbed by enzymatic degradation or hydrolysis. It is important to note that accelerated absorption may take place when there is excessive moisture or fluid, or if sutures become wet during handling. Nonabsorbable sutures trigger an immune response that results in fibroblasts forming a capsule around the suture. (Ratner, 1994). When nonabsorbable sutures are used on the skin, they will be removed once the wound is healing and supporting itself; however, if these sutures are used within the body, they will stay within the tissue. (Medscape, 2015). Some examples of absorbable sutures include Monocryl, Vicryl, PDS, and chromic gut. The rates of absorption for these sutures can vary greatly. For example, Vicryl breaks down in about 2 weeks, while PDS lasts about 9 weeks. The rates of absorption of the suture depend on patient factors as well. Fever, infection, or protein deficiency can all increase absorption rates. Examples of nonabsorbable sutures include Nylon, Silk, Ethibond, and Prolene. (Medscape, 2015) Suture Sizes The United States Pharmacopeia standardizes sizes of sutures. The size determination is based on a certain diameter in millimeters that is required to produce a specific tensile strength. Sizes are expressed in terms of zeros, such as 3-0 (pronounced three-oh). Higher numbers, and therefore more zeros, indicate a smaller size. Therefore, a 6-0 Prolene suture is smaller and carries less tensile strength than a 2-0 Prolene suture. (Medscape, 2015) Common Suturing Techniques There are several different suturing techniques. A few common suture techniques include the simple interrupted suture, the simple running suture, the vertical mattress suture, the horizontal mattress suture, and the running subcuticular suture. Simple Interrupted Suture The simple interrupted suture is very common in a variety of scenarios. It is frequently used for skin closure. This type of suture is commonly used in the emergency department for laceration repairs, but can also be used to approximate the skin of surgical wounds. The stitches are simple because the needle enters the skin on one side of the wound, exits on the other side of the wound, is pulled to bring the sides together, and is tied. Each stitch is placed individually, and stitches aren t connected. (Lammers et al, 2004) Simple Running Suture A simple running suture is an uninterrupted sequence of simple sutures. Simple interrupted sutures are preferred to simple running sutures if there is suspicion that the wound may become infected. If a wound does become infected, it is easier to remove a few simple interrupted sutures where the infection is draining, rather than removing the entire length of the suture if a running suture is placed. (Wong, 1993) 4

5 Vertical Mattress Suture The vertical mattress suture is another common suture type for closure of skin wounds. This type of suture brings together superficial and deep layers, and also helps to evert the skin for better wound healing. This stitch is placed by first inserting the needle on one side of the wound, far from the wound. The needle comes out on the opposite side of the wound, again far from the wound. The needle is then reinserted on the second side, but this time closer to the wound. The needle then comes out the first side of the wound, closer to the wound, and is tied. (Zuber, 2002) Horizontal Mattress Suture Similar to the vertical mattress suture, the horizontal mattress suture is also able to evert the skin edges. However, the horizontal mattress sutures are also able to reduce tension along the wound. Therefore, this suture works well for wounds under a lot of tension. However, this type of suture can cause skin necrosis if tied too tightly, compared to other types of sutures. This suture is placed by inserting the needle on one side of the wound and bringing it through to the second side. The needle is then advanced slightly and is reinserted on the second side of the wound. The needle is brought through to the first side of the wound and the suture is tied. (Zuber, 2002) Running Subcuticular Suture The running subcuticular suture is very commonly used to approximate the skin of surgical wounds. This is a buried variation of the horizontal mattress suture. With this technique, no suture is visible. An absorbable suture is used, and it will resorb after several weeks. (Adams et al, 2006) Module Two This module will discuss the use of surgical staples and how surgical glue has been incorporated into surgical practice. Staples Staples are often used as a method of wound closure. Staples have a long history with Humer Hültl developing the basis for the surgical stapler in the early 1900s (Chekan & Whelan, 2014). The automatic skin stapler was introduced in 1972 for widespread use. Staples are effective due to their ease of use and the time savings staples provide during wound closure. Staples are most often made of stainless steel, but absorbable staples are now available. They are applied to the skin via a disposable stapler and allow for rapid wound closure. The staples cross the wound perpendicularly with each prong of the staple going through the patient s skin on either side of the wound. Like sutures, approximation of the wound is maintained through securing the tissue. Most staples are bent into a B-shape to allow for this tissue securement (Chekan & Whelan, 2014). Staples are commonly used in gastrointestinal, gynecological, urologic, vascular, cardiothoracic, orthopedic, head, neck, and hand surgeries. Staples vs Sutures Literature is inconclusive about whether wound infection is more prevalent when staples are used versus sutures. Some studies indicate that the incidence of wound infection is less when staples are used since they do not penetrate the wound but only cross the incision site and they have lower tissue reactivity than sutures. Other studies show that staples increase the risk of wound infection (Smith, Sexton, Mann, & Donell, 2010). However, when looking at time constraints, the amount of time taken to staple a wound closed is significantly less than the time required to suture a wound (Iavazzo, Gkegkes, Vouloumanou, Mamais, Peppas, & Falagas, 2011). 5

6 There have been reported cases of increased pain related to the use of staples when compared to sutures. This is particularly true when removing the staples. The final cosmetic results of staples was found to be similar as compared to sutures. Staple Removal In recent years, surgical glue has become increasingly utilized in operating rooms. Surgical glue has become an important tool for surgeons in various aspects of surgery, including in wound closure. There are many advantages of skin glue, as well as some disadvantages. These will be further discussed throughout this module. Development of Surgical Glue The use of chlorhexidine gluconate, at least 0.5% in seventy percent alcohol, is recommended for site preparation. The inserter must follow the manufacturer s directions for use for this product, which involves a vigorous back and forth scrub for at least 30 seconds in a dry area, or 2 minutes on an area of skin that is moist (such as the groin). Scrubbing in back and forth motions with friction helps to get the antiseptic into the top five layers of the skin, where eighty percent of the pathogens reside. The remaining twenty percent of the pathogens reside in the hair follicles and sebaceous glands, and will come to the surface as the patient perspires, produces oil and has sloughing of skin cells. For this reason the skin can never be considered sterile, even after it has been properly scrubbed. Following this scrub, allow for complete drying of the cleansing agent, according to the manufacturer s time guidelines. (Gorski et al., 2016, S38; Harpel, 2013; Han, Liang, & Marschall, 2010; O Grady et al., 2011) Uses of Surgical Glue Surgical glues can be referred to as surgical tissue adhesives or sealants. These products can be used for closure of surgical wounds and for approximating tissues in traumatic injuries. The materials in the glue form a chemical bond to hold the tissue together. It supports the wound to help with healing and acts as a barrier to protect the wound. Surgical glues can be used independently, or in conjunction with sutures and staples. (MedMarket Diligence, 2015) Types of Surgical Glue The main types of surgical glues include fibrin sealants, gluteraldehyde-based glues, collagen-based products, and hydrogels. These are all intended for internal use only. Cyanoacrylates are a different type of surgical glue which are uniquely designed for topical use. (Reece et al, 2001) Surgical Glues for Internal Use Each surgical glue intended of internal use has unique properties. Fibrin sealants contain both human and animal blood products. When applied, the ingredients of the fibrin sealant form a clot. This type of surgical glue is commonly used in cardiovascular surgery, lung surgery, in closure of dura, and to seal liver and spleen lacerations. Gluteraldehyde-based glues are a combination of protein and adhesive compounds. The glutaraldehyde-based glue that is currently approved by the US Food and Drug Administration is used to repairing aortic dissection due to its ability to fill the dissection and form a strong internal seal. Future uses are currently being explored Collagen-based adhesive products can be used in combination with other hemostatic proteins, such as thrombin. This creates an effective internal adhesive. Hydrogels are synthetic polyethylene glycol polymers. These products are commonly used in thoracic surgery due to their ability to seal air leaks. (Reece et al, 2001) 6

7 Cyanoacrylate Glues Cyanoacrylate glues are compounds intended for topical use to close incisions or minor lacerations. Typically, subcutaneous tissues are closed with sutures, and cyanoacrylate glue is used to close only the dermis and epidermis. These glues are frequently used to close laparoscopic incisions and are much stronger than the other types of surgical glue discussed previously. Cyanoacrylates are also able to withstand the external environment while the incision heals naturally underneath the glue line. In general, cyanoacrylates are waterproof, flexible, and require no secondary dressing. Cyanoacrylates are not bioabsorbable, and therefore can only be used externally. (Reece et al, 2001) Development of Cyanoacrylates Cyanoacrylates were accidentally discovered while researchers were studying refracting indexes of coatings on glass. They were first utilized in 1949 and became popular during the Vietnam war as a hemostatic agent for soldiers wounded in field combat. They began to enter the clinical market in the 1980s and 1990s in dental products, bandages, and wound closure adhesives. Currently, many cyanoacrylates have been approved as medical devices by the Food and Drug Administration (FDA). (Silvestri et al, 2006) Types of Cyanoacrylates There are two main types of cyanoacrylates approved as medical tissue adhesives: N-butyl-cyanoacrylate (commonly called butyl) and 2-octyl-cyanoacrylate (commonly called octyl). Butyl needs refrigeration, cures as a rough surface, and sets up with a brittle glue line at the application site. Butyl glues are more prone to cracking and splitting under tension and flexion of the skin, limbs, and joints during normal movement. Octyl does not need to be refrigerated. It cures, or polymerizes, as a smooth surface with an even film. Octyl sets up with a flexible glue line at the application site. (Reece et al, 2001) Benefits of Cyanoacrylates There are many potential benefits of wound closure with cyanoacrylates. Wound closure with cyanoacrylates is much quicker than closure with sutures or staples. There is comparable or even better scar cosmesis compared to wound closure with sutures or staples. An occlusive microbial barrier is formed. The use of skin glue is non-invasive, resulting in less tissue trauma and a reduced inflammatory reaction. No secondary dressings are required. Skin glue is easy to use, and there is a quick learning curve. Skin glue allows for easy visualization of the wound. There is reduced risk of needle-stick injury associated with suturing. (Reece et al, 2001) Occlusive Microbial Barrier One key advantage mentioned is the skin adhesive s ability to provide an occlusive microbial barrier. Studies have shown that cyanoacrylate adhesives may potentially reduce the risk of surgical site infections (SSIs) by forming an occlusive, impermeable, waterproof barrier. This barrier prevents translocation of skin flora, reduces post-operative wound dressing changes, and improves hygiene by allowing patients to shower. (Malangoni, 2006) Deciding When to Use Surgical Glue for Wound Closure So why doesn t every surgeon use skin glue for every surgical wound? In determining the appropriate type of product to close any surgical wound, surgeons must take into account many factors, including the reason for the 7

8 surgery, the location of the wound, where and how the injury occurred if the wound is traumatic, and the length of the surgical procedure. Surgical wound closure using a cyanoacrylate is best suited for wounds that are not subject to significant stress or flexion. Many surgeons follow this rule of thumb: if the skin requires more than simple pulling together with forceps or fingers to achieve approximation of the wound, then deeper sutures and/ or subcutaneous suture should be used before any glue is applied. Additionally, octyl cyanoacrylates tend to work better on areas of flexion compared to butyl cyanoacrylates, as mentioned previously due to their more flexible glue line. (Reece et al, 2001) Optimizing Results The best results with skin glue are obtained when the wound is clean and dry with total hemostasis prior to application of the adhesive. Cyanoacrylates close the skin by forming a polymerized layer across the top of the skin, creating a bridge between the skin edges. Therefore, it is important to obtain edge-to-edge apposition while the glue sets over the wound. (Reece et al, 2001) MODULE Three This module will discuss the postoperative care of surgical wounds. Postoperative Wounds Each surgical wound is unique and should be cared for as such. There are many important factors to consider when caring for a patient with a surgical wound, including patient comfort, infection prevention, and pressure \ injury prevention. Postoperative Wounds Postoperative patients will generally have orders given by their surgeon regarding how to care for their wound. The surgeon will specify when and how frequently the dressing should be changed, if at all. Dressings may simply be a covering over the wound, or may be more complex such as packing in the wound or a negative pressure wound vac. If you ever feel that you do not have enough experience to care for a certain type of wound, be sure to ask for help. Wound care nurses can be a great asset for all types of wounds, including postoperative wounds. While it may not be possible to keep the patient completely comfortable during wound care, nurses should take every measure possible to maximize comfort. Incision Care Wound care is unique to the type of wound and how it is closed. As discussed in Module One, there are three types of wound closure: primary closure, secondary closure, and delayed primary closure. Most surgical wounds are closed primarily. These wounds are typically covered with a sterile dressing for 24 to 48 hours. This allows epithelialization of the wound to occur, which is thought to protect the wound from infectious pathogens outside the wound. Beyond this period, dressings can be quite variable, and often, no dressings are used at all. Dressings should be applied based on the condition of the wound and drainage from the wound. When delayed primary closure or secondary closure techniques are used, the wound is initially packed with sterile gauze and is covered with a sterile dressing. The rationale behind these techniques is that the wound is likely contaminated, and the wound should not be closed, trapping the bacteria. Thus, these wounds should be closely monitored for signs of infection. (Mangram, 1999) Surgical Site Infections Surgical site infections, or SSIs, are postoperative complications that can be devastating for the patient. It is important that nurses caring for postoperative wounds keep the wounds as clean as possible and watch for any signs of infection. 8

9 What is an SSI? The Centers for Disease Control and Prevention, or CDC, provides criteria to define a surgical site infection. The key criteria in defining surgical site infections are that the infection must be related to an operative procedure and must occur at or near the surgical site. Although SSIs are commonly localized to the incision site, these infections can extend into deeper tissues and adjacent structures. Therefore, surgical site infections can be classified as a superficial incisional SSI, a deep incisional SSI, or an organ/space SSI. (Centers for Disease Control and Prevention [CDC], 2015). Superficial Incisional SSI Superficial incisional SSIs occur within 30 days after the operation and involve only the skin or subcutaneous tissue of the incision. In order to be classified as a superficial incisional SSI, the infection must meet at least one of the following criteria: There is purulent drainage, with or without culture documentation. There are organisms isolated from the fluid or tissue of the superficial incision. The patient experiences signs of inflammation, including pain or tenderness at the incision and/or localized swelling, redness, or heat. The wound is deliberately opened by the surgeon. A diagnosis is made by a surgeon or attending physician. (CDC, 2015) Deep Incisional SSI A deep incisional SSI occurs within 30 days of the operation or within one year if an implant is present. This type of SSI involves the deep soft tissues of the surgical site, such as the muscle and fascia. At least one of the following criteria must also be met: There is purulent drainage from the deep tissues, but not from an organ/deep space being involved. There is spontaneous fascial dehiscence, or in other words, the fascia comes apart. The surgeon may also reopen the wound due to inflammation. There is a deep abscess or other evidence of infection of the deep tissues which can be found on direct examination, histopathology, radiology, or during reoperation. A diagnosis is made by a surgeon or attending physician. (CDC, 2015) Organ/Space SSI Organ/space SSIs occur within 30 days of the operation or within one year if an implant is present. This type of SSI involves anatomic structures not opened or manipulated during the operation. In order to be classified as an organ/space SSI, at least one of the following criteria must also be met: There is purulent drainage from a drain placed by a stab wound into the organ or space. Organisms are isolated from the organ or space by aseptic culturing technique. An abscess in the organ or space is able to be identified by direct examination, histopathology, radiology, or during reoperation. A diagnosis is made by a surgeon or attending physician. (CDC, 2015) 9

10 Wound Care and SSIs Here are some tips nurses can use in caring for postoperative wounds to help minimize the risk of infection: Utilize appropriate hand hygiene and aseptic technique when caring for surgical wounds Follow instructions on dressing changes and try to minimize unnecessary changes to avoid disrupting healing tissue Encourage appropriate patient hygiene to maintain a clean environment Always consult the surgeon and/or wound care nurses for wounds that do not appear to be healing appropriately Educate patients and caregivers on appropriate wound care Postoperative Pressure Injuries Pressure injuries can be a significant postoperative complication related to wound care. Not only can pressure injuries develop at bony prominences, but also around the postoperative wound itself. Pressure exerted from medical devices such as oxygen tubes, catheters, or compression devices for DVT prevention can also cause skin injury. Bandages may prevent or delay the visualization of affected tissues. Because development can occur within a few hours of surgery, a pressure injury may progress rapidly before a patient s bandages are changed or removed. Therefore nurses caring for postoperative patients must conduct thorough skin assessments to ensure that no potential pressure injury is missed. (Conner, 2015) The postoperative skin assessment should include notation of all skin irritations, redness, bruising, and swelling, as well as skin temperature, skin color, turgor, moisture status, and integrity. (Coleman, 2013) Caring for Postoperative Wounds While there are many factors involved in postoperative wound care, you should not feel overwhelmed. There are always other healthcare personnel to assist you and make sure you are taking the best care of your patient. Always familiarize yourself with your institution s policies regarding wound care. Module four This module will discuss general discharge instructions for patients with postoperative wounds. Discharge Instructions As in caring for postoperative wounds while the patient is in the hospital, discharge instructions for wound care can vary from patient to patient and from surgeon to surgeon. This module will discuss some general instructions patients should follow when caring for their postoperative wound at home. Throughout this module, remember to check with your patient s surgeon to verify their specific home care orders. Discharge Planning & Instructions Patients are regularly discharged before their wound has fully healed. Therefore, thorough discharge instructions for appropriate wound care are needed. Nurses and other members of the healthcare team should make every attempt to ensure the patient understands exactly how to care for their wound. Patients should be encouraged to contact their surgeon s team with any questions about their wound. (Mangram, 1999) Dressing Changes Patients should be instructed on how frequently their dressing should be changed or if it should be changed. Often when incisions are closed with sutures or staples, the overlying bandage should stay in place for 48 hours. After this time, it may or may not be replaced. The surgeon will determine whether the wound should stay covered beyond 10

11 48 hours, and this information should be thoroughly explained to the patient. If butterfly closure strips are in place, these should be kept dry for 48 hours. Patients should be instructed that these strips will eventually fall off on their own, and that they should not be picked at. If staples or visible sutures are in place requiring removal, the patient should have clear instructions regarding their follow-up to have them removed by a healthcare professional. This is typically done within 7-10 days. (East Jefferson General Hospital [EJGH]), 2015) If an incision is closed with surgical glue, there may not be an overlying dressing. Patients should be instructed that the glue will eventually peel off, and they should not pick at it prematurely. (Reece et al, 2001) Showering Generally, patients are instructed that they can shower 48 hours after surgery. However, be sure to check with the patient s surgeon as this is not always the case. Patients should be instructed to gently let the soapy water flow over the incision without rubbing the incision. Patients should not soak in the bathtub until instructed by their surgeon. (EJGH, 2015) Activity Activity instructions can vary greatly, depending on the patient s wound and other injuries, if present. Be sure to inform your patient of their permissibly activity level as activity can be vital in preventing deep vein thrombosis. Patients should be instructed to rest when they are feeling tired. Many procedures will have specific weight lifting restrictions, which the patient should understand. Patients should also be instructed not to drive or operate machinery while taking any prescribed pain medications. Diet Again, diet recommendations can vary greatly from patient to patient. Patients should be instructed to drink plenty of water and to eat plenty of protein and other foods to help promote wound healing. Special Considerations Some patients will have surgical drains or more complicated wounds, such as those with wound vacuums or those that are open with packing. Be sure to take extra time prior to discharge to ensure these patients understand how to care for their wound at home. When to Call the Doctor Patients should be instructed to call their surgeon s office under the following circumstances: If they develop a temperature greater than 101 degrees Fahrenheit. If redness or swelling develops around the incision, or if pus drains from the incision. If they develop severe or worsening pain. Patients should call 911 in the case of any emergency, such as chest pain or shortness of breath. Conclusion When caring for postoperative wounds, always keep the following points in mind. Each surgical wound is unique, and there are many different factors to consider when caring for a postoperative wound, from the initial reason for the surgery to the way the wound was closed. If you feel overwhelmed in caring for a surgical wound, ask for help. Be sure to provide thorough education to patients regarding wound care prior to their discharge, including any unique instructions given by the surgeon 11

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