Title Guideline: The Management of People with Open or Closed Surgical

Wounds
Backgroun See “Guideline: The Assessment of People with Open or Closed Surgical Wounds”
d
Indication This guideline is intended to be used by health care providers, to guide their
s management of individuals admitted/presenting with a surgical wound.
Guideline Healable Wounds – Closed Surgical Incisions
1. Upon completion of a thorough, holistic patient and wound assessment, follow the
surgeon’s orders. If there are concerns regarding the orders or orders are missing
contact he surgeon immediately for direction. Below are some general principles for
a closed surgical wound. However these principles do not supersede physician
orders.
2. Leave the post-op surgical dressing in place for 48 hours, reinforcing it as needed if
breakthrough drainage occurs.
3. Monitor for dehiscence and notify the surgeon IMMEDIATELY should it occur.
4. 48 hours post-op, remove the initial surgical dressing and, using sterile technique,
cleanse the incision line from the proximal to distal aspect (or clean to dirty) to
remove any drainage. Air dry or gently pat dry with sterile gauze.
5. Depending on the type of surgery, comfort of the patient with the wound, and
organizational policy, you may need to reapply a sterile dry dressing. If there is no
policy in place and the incision is approximated, dry, and free of signs of
infection/complications, the incision may be left open to air, unless otherwise
ordered by the surgeon
6. If you re-apply a sterile surgical dressing, choose an appropriate dressing change
frequency based on:
i. Your wound assessment, including the patient’s risk for infection
ii. Dressing products used and their ability to manage the drainage anticipated
7. Remove sutures/staples as ordered or direct the patient to the appropriate health
care professional for the removal of their sutures/staples as per the surgeon’s
orders. If you are to remove the sutures:
i. Using sterile technique cleanse the incision using an antiseptic swab from
proximal to distal or clean to dirty aspect
ii. Remove sutures or staples using aseptic technique with sterile tools. NOTE:
you may choose to remove every other suture/staple initially and then
observe the incision line to determine whether or not the incision line will
remain intact. If you anticipate that the incision line may dehisce with the
removal of the remaining sutures/staples, STOP removing staples/sutures
and let the surgeon know
iii. Gently cleanse the incision line once again with an antiseptic swab, from
proximal to distal or clean to dirty aspect. Air dry
iv. Apply a sterile non-stick island dressing if needed, otherwise leave the
incision open to air

Healable Wounds – Open Surgical Wound or a Closed Surgical Wound that has
Dehisced or Eviscerated

Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 1
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 8. Upon completion of a thorough, holistic patient and wound assessment cleanse the
wound with an appropriate wound cleansing solution using non-touch aseptic
technique. Make sure to cleanse away wound surface debris.
NOTE: follow the manufacturer’s instructions when using a wound cleansing
solution
9. Debridement of loose, non-viable tissue in the wound should be performed by a
trained health care provider who has the knowledge, skill, and competency to do so.
Please refer to your respective college and employer’s policies and procedures
before undertaking this task. For further guidance see “Guideline and Procedures:
Wound Debridement” and “Guideline and Procedure: Conservative Sharp Wound
Debridement”
10. Cleanse the wound again post debridement. Gently pat the wound dry with dry
sterile gauze
11. Choose an appropriate conventional moist wound dressing or combination of
dressings. Consider choosing a dressing that will:
i. Promote an ideal moist wound healing environment
NOTE: only use a packing or cavity filler dressing that can be removed in
one piece, i.e. a product with adequate tensile strength so that it does not
fall apart in the wound leaving fragments behind, and do NOT pack tightly.
NOTE: if underlying mesh, implants, or exposed underlying structures are
evident in the wound bed, apply a non-adherent dressing over the areas to
prevent the primary dressing from sticking
ii. Minimize contamination
iii. Prevent strike through of exudates while wicking moisture away from the
wound surface
iv. Be cost effective
v. Be comfortable to wear, not causing increased pain during wear time or on
removal
12. Choose an appropriate dressing change frequency based on:
i. Your wound assessment, including the patient’s risk for infection
ii. Dressing products used and their ability to manage the drainage anticipated
iii. The patient’s comfort and acceptability

Non-Healing/Non-Healable Wounds – Open Surgical Wound

13. If it is determined that the wound in question is not-healing or not-healable due to
intrinsic and/or extrinsic factors that are impeding healing (based off of the health
care providers holistic assessment and clinical judgement) cleanse the wound with
an appropriate wound cleansing solution and follow the manufacturer’s instructions
14. DO NOT DEBRIDE
15. Paint and/or cleanse the wound with antiseptics and allow the antiseptic to air dry
16. Choose an appropriate dry gauze based non-adherent dressing or combination of
dressings unless otherwise directed by a physician or nurse practitioner. Choose a
dressing that will:
i. Promote a dry wound environment and that will minimize bacterial
contamination
ii. Prevent strike through of exudates while wicking moisture away from the
wound surface
Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 2
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 iii. Be cost effective
iv. Be comfortable to wear, not causing increased pain during wear tie or on
removal
17. Choose an appropriate dressing change frequency based on:
i. Your wound assessment, including the patient’s risk for infection
ii. Dressing products used and their ability to manage the drainage anticipated
iii. The patient’s comfort and acceptability

Management Guidelines for ALL Surgical Wounds

Treat the cause:
18. Modify any identified intrinsic, extrinsic, and iatrogenic factors affecting wound
healing to promote the healing of the surgical wound and to prevent
infection/complications
19. Provide or encourage the use of an offloading device if the patient has a surgical
wound on the plantar aspect of their foot and has diabetes and/or has loss of
protective sensation. Communicate with the surgeon and member of the SWRWCP
if further direction/guidance is needed.
20. In the presence of a surgical wound on the leg of a patient with venous or mixed leg
disease, initiate appropriate compression therapy as directed by the surgeon.
21. Patient centered concerns:
22. Manage pain through advocacy and collaboration with the patient and primary
health care provider. Considerations may include encouraging the patient to take
their pain medication prior to dressing change, non-pharmacological methods such
as distraction/guided imagery.
23. Ensure the plan of care is created with input from the patient and/or their caregiver,
including their concerns, motivations, abilities and preferences for treatment
24. Infection control:
25. Teach that new onset or worsening pain may be a sign of infection and requires
immediate medical attention
NOTE: Topical antimicrobials can be used to reduce bacterial burden in the
presence of superficial wound infection, but never take the place of systemic
antibiotics when those are needed for deeper infections
26. If you are not sure of the nature of the infection, choose a non-occlusive dressing as
the secondary dressing. Dressing frequency for infected surgical wounds should be
increased until the symptoms of the infection are progressively improving
27. Implement strategies to prevent infection, i.e. proper hand washing and infection
control measures
28. Drain management:
29. Identify the presence, number, and location of closed wound drainage systems, and
inspect to ensure proper functioning (teach the patient to inspect regularly for
function if they are assuming the responsibility of managing their drain)
30. Using aseptic technique, empty the contents of the drain at least daily and measure
the contents, recording the amount (teach the patient with the drain to do so if they
are assuming responsibility for managing their drain)
31. Change drain dressings as needed/ordered using aseptic technique and gauze based
products
32. Remove the drain as ordered by the surgeon
Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 3
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 33. Advocate for or request interdisciplinary referrals:
34. Wound Care Specialists for conservative sharp debridement, treatment planning,
adjunct therapies
35. Registered Dietician for diet, nutrition, supplementation, weight control
36. Speech Language Pathologist for presence or risk of developing a swallowing
impairments
37. Physiotherapy for mobility/exercise plan, mobility/gait/range of motion assessment,
adjunctive therapies for wound healing and/or neuropathic pain management
38. Occupational Therapist for assistive devices, modifications to activities of daily living,
fall risk assessment and recommendations
39. Orthotist/Pedorthist/Podiatrist for appropriate footwear/offloading device,
professional foot care
40. Social Work for psychosocial and economic/community supports

41. Education for the patient and/or support patient(s):

42. Controlling their blood sugars thru exercise, diet, and medication,
43. The effects of acute illness and infection on their blood glucose (if they have
diabetes)
44. Quitting or reducing smoking
45. Exercising regularly and eating a well-balanced diet
46. Signs and symptoms of infection/complications and when to seek IMMEDIATE help
47. Dressing change instructions, if the patient or their caregiver will be changing the
dressings
48. Supporting their incision when changing position, coughing or sneezing, and to avoid
heavy lifting for six weeks post-operatively or as directed by the surgeon
49. Monitoring and recognizing signs of dehiscence, including bruising at the wound site,
localized pain, wound inflammation and exudate, skin breakdown around the
wound, and nausea/vomiting
50. To follow surgeon’s instructions regarding bathing and staple, suture removal.

51. Provide resources/links to reinforce health teaching:

52. SWRWCP “My Surgical Wound” available at:
https://swrwoundcareprogram.ca/Uploads/ContentDocuments/SWRWCP_Surgical
WOUND.pdf
53. SWRWCP “My Hemovac Drain” available at:
https://swrwoundcareprogram.ca/Uploads/ContentDocuments/SWRWCP_Hemovac
DRAIN.pdf
54. SWRWCP “My Jackson-Pratt (JP) Drain” available at:
https://swrwoundcareprogram.ca/Uploads/ContentDocuments/SWRWCP_JacksonP
RATT.pdf
55. SWRWCP “My Skin Graft” available at:
https://swrwoundcareprogram.ca/Uploads/ContentDocuments/SWRWCP_SkinGRAF
T.pdf

56. Re-evaluate

Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 4
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 a) Regularly and consistently measure the wound, weekly at a minimum, using the
same method
b) Conduct a comprehensive reassessment to determine wound progress and the
effectiveness of the treatment plan, i.e. Using the NPUAP PUSH Tool 3.0”,
weekly at a minimum
c) Calculate the % reduction in wound surface area to ensure that the wound is
closing at an expected rate, i.e. 20-30% over three-four weeks treatment is
predictive of timely wound closure
d) If the wound is not healing at an expected rate despite the implementation of
best practice interventions, you may need to consider:
i. Update the primary care provider and wound care specialist
ii. Re-evaluate plan of care and advocate for or request referrals
iii. Discuss barriers or challenges with the patient
e) Reassess pain at EVERY dressing change and more frequently as reported by
the patient, using the same pain tool/scale each time. Report pain
management issues to the patient’s primary care physician or primary care
nurse practitioner

57. Notify the primary care physician or primary care nurse practitioner immediately if
the following occur:
a) Acute onset of pain or increasing pain
b) Wound probes to bone (if this is a new finding)
c) Gangrene develops or worsens
d) Rest pain develops in the foot
e) Previously palpable peripheral pulses are diminished or absent
f) Signs of localized and/or systemic infection develop
g) The patient hemorrhages
h) The wound dehisces or eviscerates. If the wound eviscerates:
i. Place the patient in a low Fowler’s position with knees bent
ii. Cover any exposed tissues with dressings moistened with warm, sterile
normal saline
iii. Do not attempt to push exposed viscera back into the abdomen
iv. Depending on the health care setting, call 911 or notify a physician
IMMEDIATELY
v. Remain with the patient to monitor for shock and vital signs until seen by a
physician or until the ambulance arrives

58. Documentation:
a) Document initial and ongoing assessments as per your organizations guidelines
b) Document care plans, implementation strategies, and outcome measurements
as per your organizations guidelines

Outcomes 1. Intended:
a) Closed surgical wounds:
i. Visible inflammatory response post-op x 4 days
ii. Well aligned incisional edges with no tension

Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 5
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 iii. Reduction in wound exudate and change in appearance of exudate –
trending towards serous
iv. Healing ridge should be palpable days 5-9 along the entire length of the
incision
v. Complete removal of all external suture materials per the surgeons direction
vi. Flattening, softening and lightening of the incisional scar days 15 through 1-
2 years
b. Open surgical wound fills with granulation tissue, re-epithelializes, and
drainage ceases, in a timely manner,
c. The wound is maintained and infection free if the wound is deemed ‘non-
healing or not-healable’
d. The patient indicates that pain is resolved, improving, or manageable
e. The patient does not develop a SSI
f. The incision does not hemorrhage or dehisce
g. The patient and/or their caregiver understands their role in wound healing
and participates in supporting wound healing
h. The patient can identify signs and symptoms of infection/complications, and
can describe who, how, and when to seek help
i. The patient becomes independent in self-management of their wound
2. Unintended:
a) Closed surgical wounds:
i. Prolonged state of inflammation, i.e. greater than day 4 post-op
ii. Absence of a palpable healing ridge days 5-9
iii. Increase in exudate or new drainage from a previously ‘healed’ incision
iv. Incisional hematoma formation
v. SSI
vi. Wound dehiscence/evisceration
vii. Retained sutures/staples
viii. Re-injury of the incision line, i.e. herniation
ix. Keloid or hypertrophic scarring

b) Open surgical wound does not close in a timely manner

i. The wound becomes infected
ii. The patient develops gangrene
iii. The patient expresses concerns about poorly managed pain
iv. The patient requires an amputation where one was not anticipated
v. The patient does not understand their role or participate in supporting
wound healing
vi. The patient does not understand the signs and symptoms of
infection/complications, and when, how, and whom to seek help from
vii. The patient does not become independent in self-management of their
wound
Reference 1. Johnston, D., et al. 2018. Surgical wound care guideline. Available at:
s http://bestpracticeinsurgery.ca/guidelines/surgical-wound-care/ [Accessed 23 June
2020].

Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 6
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work
 2. Sandy-Hodgetts, K., et al. 2020. International best practice recommendations for the
early identification and prevention of surgical wound complications. Wounds
International. Available at: www.woundsinternational.com [Accessed 23 June 2020].
3. Morgan-Jones, R., et al. 2019. Incision care and dressing selection in surgical
wounds: findings from an international meeting of surgeons. Available at:
www.woundsinternational.com [Accessed 23 June 2020].
4. Harris, C., et al. 2018. Best practice recommendations for the prevention and
management of surgical wound complications. Available at:
https://www.woundscanada.ca/docman/public/health-care-professional/bpr-
workshop/555-bpr-prevention-and-management-of-surgical-wound-complications-
v2/file [Accessed 23 June 2020].

Surgical Wound Management Guide | South West Regional Wound Care Program | Last Updated June 2020 7
Developed in collaboration with SWRWCP Stakeholders and Health Care Partners
NOTE: this is a controlled document. A printed copy may not reflect the current electronic version on the SWRWCP’s website. This document is not a substutute for proper training,
experience, and excercising of professional judgment. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the
SWRWCP give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or
omissions in the contents of the work