Surgical Wound Healing

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Surgical Wound Healing A REVIEWFOR PERIOPERATIVE NURSES Annette B. Wysocki, RN urgical wound healing is a dynamic process that begins when the incision is made. Progression to complete healing usually follows an orderly sequence. This article reviews the stages of wound healing and their related cellular processes, describes two basic approaches to dressing surgical wounds, and summarizes some current areas of wound-healing research.

The Skin

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he skin is the largest organ of the body and the one most frequently affected by surgery. In the average adult, the skin

Annette B. Wysocki, RN, PhD, C, is a postdoctoral fellow in cell biology and anatomy at the UniversiQ of Te2vusSouth western Medical Center, Dallas. She earned both her bachelor and masler of science degrees in nursing from East Carolina University,Greenville, and her doctorate of philosophy in nursing from the University of Texas at Austin. 502

covers about 3,000 square inches and is nearly one sixth of the total body weight. It receives about one third of the circulating blood volume (approximately 1.6 L).' Major functions of the skin include protection, sensation, thermoregulation, and metabolic functions, such as the synthesis of vitamin D.2In addition, the storage of adipose tissue provides a ready metabolic energy source. Collagen is the major structural component of skin and constitutes about one half the total body protein. Type I and Type 111 collagen are fiber forming and found in skin and healing wounds. Type I represents 85% of the collagen present, and Type I11 represents 15'70.~ Skin is characterized by two major layers: epidermis and dermis. The epidermis is composed of five layers and is derived from ectoderm, the outermost embryonic germ layer. The top layer of the epidermis consists of dead keratinized cells, called the stratum corneum. It is continuously shed and replaced by cells migrating from the stratum basale, the innermost layer where mitosis (cell division) occurs. The dermis is derived from mesoderm, which is the middle embryonic germ layer. Blood and lymph vessels, nerves, hair follicles, and sweat and sebaceous glands are found in the dermis.

Wounds

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wound is any interruption in the continuity of body tissue. Wounds are classified as with or without tissue loss. Chronic wounds (eg, leg ulcers and pressure sores), burns, and debrided wounds exemplify wounds

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Fig 1. Wound closure by primary intention using staples in an abdominal colectomy.

Fig 2. Wound closure by secondary intention in a venous leg ulcer. Note the beefy red granulation tissue. with tissue loss. Surgical incisions usually result in wounds without tissue loss. The etiology of wounds includes surgical-incisions or excisions, traumatic-caused by mechanical trauma or thermal injury, and chronic-exemplified by pressure sores or venous leg ulcers. Wound closure occurs by primary, secondary, and delayed primary or tertiary intention. Most surgical wounds are closed by primary intention504

the edges of a wound are approximated with sutures, staples, or tape (Fig 1). Wounds that are successfully closed by primary intention are at low risk for infection and have a minimal amount of drainage and tissue loss. The epithelial edges are glued together by a fibrin/ fibrinogen/fibronectin bond! Fibronectin is a glycoprotein found in cells and circulating plasma. It is a type of biological glue that attaches cells to extracellular matrix material. After 48 hours, epithelial cells migrate over the

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dermis, and after five to eight days, the epithelium unites. Primary healing wounds that are taped are more resistant to infection because, unlike sutures, tape does not act as a drain, create its own small wounds, or incite an inflammatory respon~e.~ Most chronic wounds and wounds with tissue loss close by secondary intention. Often these wounds have heavy bacterial contamination. In secondary intention closure, wounds develop granulation tissue, which is made of new capillaries supported in a network of collagen fibers. It is recognized by its pink to beefy red appearance (Fig 2). Epithelization (ie, the migration of epithelium over the granulating base) completes the resurfacing of the wound. Contraction and excessive scar formation are likely to be seen in wounds that heal in this fashion.6 Delayed primary or tertiary wound closure is used when significant bacterial contamination of the wound has occurred, and subsequent closure with tape, staples, or sutures seems likely. Superficial layers are left open and may be loosely packed. The dressing is not disturbed for at least four days unless indicated. Research on wounds that have been experimentally infected with Staphylococcus aurem shows that after four or more days, closure of the wound results in negligible infection? Delayed primary closure is successful as long as there are less than 100,000 organisms present per gram of tissue.* Despite later closure, tensile strength is about the same as that in a wound closed primarily by the seventh postoperative day? Debridement of wounds healing by secondary or tertiary intention can be accomplished by mechanical or chemical means. For mechanical debridement, a scalpel or wet-to-dry dressings are used. For chemical debridement, an enzymatic debrider is used; this is usually restricted to use with chronic wounds.

Stages of Healing

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ound healing occurs as a series of overlapping and often simultaneous stages and is the process whereby the continuity of the injured tissue is restored. Healing at the cellular level is classified into three stages:

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inflammation, proliferation, and maturation.1° A summary of the stages of wound healing and their respective times, evenls, and cell types are summarized in Table 1. For clarification, one author also adds the destructive phase, which occurs following inflammation.1i The stages of healing described in this article refer to normal surgical wound healing as opposed to chronic wound healing. Inflammation. The inflammatory stage begins as soon as the surgical incision is made and lasts for four to five days. This stage is easily recognized by the four cardinal signs of inflammation: redness, heat, pain, and swelling. Two major events of this stage are hemostasis and phagocytosis. Hemostasis is achieved via a series of events beginning with vasoconstriction. Initially, blood pours into the wound anid together with platelets forms a primary seal. Thiis is followed by a period of histamine-initiated vasodilation, which increases vascular permeability by releasing leukocytes and other macromolecules into the wound. The composition of the secreted fluid is similar to circulating plasma. Neutrophils are the most common leukocytes, constituting 40%to 75% of circulating white cells. They appear at the site of injury six hours after the wound is made and remain in the wound up to five days. Together with macrophages, the largest white cells, neutrophils assist in the removal of debris and bacteria. Research indicates that neutrophils are not necessary in normal repair, but if gross bacterial contamination exists, their presence is essential.l2 Mxrophages actively carry out phagocytosis by engulfing and digesting bacteria and dead tissue, in both aerobic and anerobic conditions. Macrophages also play a role in signaling for fibroblasts and neovascularization. Lymphocytes, the smallest white cells, also are present at this stage. They comprise 20% to 45% of the differential cell count and play a key role in immune responses, always acting against specific foreign agents.13 Proliferation. Epithelization, neovascularization, and collagen synthesis occur during the proliferative stage of healing, which begins during the inflammatory stage and ends approximately 22 days later Epithelization begins within 24 hours 505

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Table 1

Surgical Wound Healing Stage

Time

Events

Cell(s)

Inflammation (0 to 4 days )

0 to 2 hours

hemostasis

0 to 4 days

phagocytosis

1 to 4 days 2 to 7 days 2 to 22 days 2 to 20 days

epithelization neovascularization collagen synthesis contraction collagen remodeling

platelets erythrocytes leukocytes neutrophils macrophages

Proliferation (2 to 22 days)

I

Maturation (21 days to 2 years )

after surgery, when epidermal cells begin to migrate beneath the surface clot and over and through a fibridfibronectin matrix. After 48 hours, epithelial cells have bridged the wound. Neovascularization is the formation of new capillaries from existing vessels. The endothelial cells are the most active in this process, which begins within two days after surgery and reaches its peak activity by the eighth day. The increased cellular activity of the healing wound requires these new capillaries for oxygen and nutrients. The abundance of the new capillaries accounts for the pink color bordering the edges of healing wounds. After six to 18 weeks, there is a decrease in vascularity as the inflammatory process is resolved, and normal skin color gradually returns. Collagen synthesis is the major activity of fibroblasts. The secretion of collagen by fibroblasts occurs in an acid environment, due to the presence of lactate, in which certain nutrients such as vitamin C, zinc, magnesium, and other amino acids are necessary.14 Following intracellular signaling, collagen is synthesized in the rough endoplasmic reticulum and is transported to the cell surface by the Golgi apparatus. Polymerization and formation of collagen fibrils is accomplished after further extracellular processing. Compared to normal 506

keratinocytes endothelial fibroblasts myofibroblasts fibroblasts

nonwounded tissue, these collagen fibrils are small and highly disorgani~ed.~~ Although collagen can be found in the wound by the second day, peak collagen synthesis occurs from the fifth to the seventh day in a primary healing wound. In some wounds, collagen synthesis continues for more than a year. The major contribution of collagen to the healing wound is tensile strength. Tissues regain tensile strength at varying rates. For example, colon, bladder, and stomach tissue quickly regain peak tensile strength in about 21 days, compared to 70 days for skin.I6 Contraction, which is propagated by the myofibroblasts, was first described in 1970.” Although it is a part of the second stage of repair, contraction is negligible in the majority of surgically incised wounds. It is a major feature of repair in chronic wounds, however, and in wounds with tissue loss. Maturation. Collagen remodeling occurs in the last stage of healing and lasts from 24 days to more than one year. It is the process in which new collagen fibers are deposited along lines of mechanical tension, and other fibers are being lysed and removed. Collagenase, an enzyme secreted by neutrophils and macrophages, is responsible for collagen lysis.

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Table 2

Factors Aflecting Wound Healing Systemic

age smoking obesity stress anemia uremia malnutrition corticosteroids chemotherapeutic agents length of preoperative stay vitamin deficiency (C, A, B, K) trauma hypovolemia hypoxia mineral deficiency (zinc, copper, magnesium) underlying pathology (diabetes, cancer) surgery (more than 3 hr) night or emergency surgery

Local

surgical technique blood supply mechanical stress suture materials suture technique radiation infection oxygen tension antiseptics presence of drain preparation of operative site

Simultaneously with the gradual removal of the primarily deposited collagen found in the second stage of repair, fibroblasts synthesize and secrete new collagen, which becomes increasingly thick and compact. Sutured surgical wounds attain their greatest collagen accumulation by about the third week, thus signaling the onset of the third stage of repair, maturation. As maturation progresses, tensile strength increases, and the healing ridge or scar diminishes. After six weeks, most wounds have 50% of their original tensile strength. With few 508

exceptions, most wounds never fully recover their original nonwounded tensile strength. Scars progress from the soft, fine, fragile tissue that is present from the time of surgery to four weeks postoperatively to an intermediate stage that occurs between four and 12 weeks postoperatively. At this time, they become white, avascular, supple, and loose mature scars. Compared to wounds with tissue loss, surgically sutured wounds have minimal scar tissue. In either case, there is a noticeable absence of hair follicles, glands, and melanocytes in the scar tissue.

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Table 3

Incidence of Infection in Relation to Wound Classification* Incidence of wound infection Clean Clean/contaminated Contaminated Dirty

Percent (%) I to 5 3 to 11 10 to 17 more than 27

* B Fernsebner, “Infection control survey: Identifying compliance with guidelines,” AORN Journal 43 (Apnl 1986) 893. Factors Affecting Healing

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any factors that influence healing have been identified. Some factors may or may not be directly influenced by the surgical team’s actions. These factors may be broadly divided into two categories, systemic and local (Table 2). Among the systemic factors is malnutrition. Especially important for collagen synthesis are ascorbic acid, magnesium, copper, zinc, and amino acids. Hypovolemia also results in a local decreased oxygen tension. The endocrine response of trauma victims further impairs the availability of oxygen to wound tissue, resulting in increased catabolism. Several factors are directly under the control of the surgical team. Tissue oxygen tension has been found to increase with local hyperthermia.l* Increased oxygen tension has been effective in reducing bacterial contamination; therefore, local heat is an effective treatment for contaminated wounds in addition to relieving pain and ~welling.’~ This data further supports the use of warm saline for wound irrigations and the warm water routinely used for sitz baths. Of primary importance in any surgical procedure is the extent of wound contamination. The higher the logarithmic dose of bacteria, the greater the incidence of infection. Surgical wound infection accounts for 32% of all nosocomial infections and is the second most common infection for surgical patients, resulting in prolonged 510

hospitalization lasting from 1.3 to 26.3 days.*O The incidence of wound infection is related to wound classification (Table 3). In clean wounds there is no break in aseptic technique. Clean/ contaminated wounds are those in the vaginal, respiratory, alimentary or genitourinary tract. Contaminated wounds result from gross spillage accompanied by nonpurulent inflammation. Dirty or infected wounds contain purulent material and often result from preexisting clinical conditions or infections. A twofold to threefold increase in wound infection has been noted in surgeries exceeding three hours, occurring at night, or done on an emergency basis.21 Preparation of the operative site also has been found to affect incidence of infection. One study found the lowest incidence of infection (0.9%) in patients who were not shaved or clipped preoperatively.2* Infection increased with use of an electric razor to 1.4%, followed by clipping at 1.7%, and shaving at 2.5%. Drains placed through a stab wound contributed to a lower incidence of infection (1.W), compared to those placed through the surgical wound (8.8%). Closed wound suction drainage had the lowest incidence of infection (0.6%). Wound healing also is affected by the type of instrument used to make the incision. In a study comparing the electrosurgical scalpel, hemostatic scalpel, carbon dioxide laser, and a standard steel scalpel, the steel scalpel was found, by histologic and tensile strength measurements, to produce the least damage to epithelial tissue.23 Epithelial

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Characteristics of the Ideal Dressing 1. Maintains an optimal physiologic environment (moist) to prevent cell dehydration or death 2. Allows free exchange of gases 3. Prevents bacterial contamination 4. Facilitates removal of excessive exudate and wound contaminants 5. Permits removal without disrupting viable cells necessary for healing 6. Does not introduce particulate or toxic materials into the ,wound I

migration began on the first day for the steel scalpel, compared to the fourth day for the hemostatic scalpel, and the seventh day for the electrosurgical scalpel and laser knife. Thermal necrotic zones were identified for all three thermal knives. Tensile strength was equivalent on the fourth day, but by the seventh day, the tensile strength of incisions made with the steel scalpel were about twice that of all three thermal knives. Although thermal knives operate with ease, coagulate tissue and vessels, and shorten surgery time, they induce changes in the cellular environment of the wound. Tissue damage due to thermal injury will delay healing. Thermal injury can be minimized by proper adjustment of the amount of thermal energy used to make the incision.

Dressings

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early all surgical wounds should be covered with a dressing for the first 24 to 48 hours for optimal resurfacing and more rapid healing.24A series of histologic sections comparing occlusion of a wound demonstrate the efficacy of using occlusive dressing materials.25 The overall function of any dressing is to provide a physiologic environment conducive to wound healing. Characteristics of the ideal dressing should be considered whenever dressing a wound. (See “Characteristics of the Ideal Dressing.”) Generally, a moist (not wet) environment promotes the best epithelial migration and protects the wound from invading microorganisms. A

dressing is acting as a substitute skin covering. Dressings have several functions.26These include pressure--to reduce edema or prevent scarring as in burn wounds, absorption-to prevent the accumulation of excessive fluid and blood thereby minimizing the chance of infection, support--to permit immobilization (eg, casts) so that healing occurs while maintaining proper bone alignment and to preserve joint motion (eg, splints), debridement--to maintain a moist wound environment and to prevent removal of newly formed epithelium (wet-to-dry dressings progressing to wet-to-wet dressings as the wound heals), hemostasis-to achieve hemostasis or ensure closure of the incision from the wound base toward the outside:; packing may be used with or without pressure (packing should be removed within 24 to 48 hours postoperatively), and symbolic-to maintain an esthetically pleasing appearance to the patient and others, to provide information about the location of the wound, and to signal that caution should be used in redressing the wound to minimize: patient discomfort.

Basic Dressin,g Techniques

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wo basic dressing techniques are the onelayer and three-hyer methods (Table 4). The one-layer method can be used on

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Table 4

Dressing Techniques

Drainage Drain Wound Healing Dressing removal

One layer

Three layer

none to slight absent partial thickness or full thickness and sutured primary 24 to 48 hr

moderate to heavy present full thickness and/or left open secondary or tertiary after 48 hr

uncomplicated, clean, primarily sutured or taped wounds in which no drain is present. This method is used for dressings that will only be in place for 24 to 48 hours. Various polyurethane dressing materials can be used for the one-layer dressing. Optimal resurfacing of superficial wounds using polyurethane dressings occurred when the dressing was applied within two hours after incision and left in place for at least 24 hours.27These occlusive materials maintain a moist wound environment, inhibit crust formation, decrease pain and inflammation, prevent bacterial contamination, and produce epithelization of superficial wounds 30%to 45% faster than air-exposed wounds.28 The three-layer technique is used for primarily closed wounds that may have drains present, secondary- or tertiary-healing wounds that are full thickness and have moderate to heavy drainage, and dressings that will be in place longer than 48 hours. The three-layer dressing consists of a contact layer, absorbant or intermediate layer, and a securing layer. The contact layer consists of dressing materials that may be occlusive, semiocclusive, or nonocclusive. Occlusive dressings prevent drying of the wound and are impermeable to air and water. Petrolatum gauze is an example. Traditionally, petrolatum gauze has been used to provide an air-tight seal around chest tubes and for open, chronic leg ulcers. Semiocclusive dressing materials include hydroactive dressings that are used for chronic wounds such as leg ulcers and pressure sores. Moderate to heavy wound drainage can limit the 514

usefulness of occlusive and semiocclusive dressing materials. Nonocclusive dressing materials facilitate removal of excessive drainage and should be nonadhering. Unless debridement is needed, gauze should be avoided as a contact layer because it will disrupt newly forming epithelium. The intermediate layer absorbs wound drainage transmitted by the contact layer. The amount, type, or thickness of the intermediate layer is guided by experience and judgment. A properly applied intermediate layer prevents excessive bulkiness, avoids patient discomfort, and avoids unnecessary pressure that may impair circulation. Absorbent layers may contain one or more 4 x 4 gauze sponges, or thick absorptive dressing pads. A top securing layer is used to keep the underlying layers in place. This can be accomplished with roller gauze, tape, Montgomery straps, stockinette material, or elastic bandage wraps. Directly taping the skin should be avoided if the patient is elderly or has fragile skin became epidermal layers are thin, and disruption and blistering are quite common.

Antiseptics

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tudies indicate that the routine use of antiseptics on surgical wounds is not good practice unless the wound has a degree of contamination known to interfere with successful wound heali11g.2~ Antiseptics may be appropriate for cleansing intact skin, but many have been shown to produce tissue injury when appIied to

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the exposed dermis, such as that found in wound healing.30 One of the most widely used surgical antiseptics is povidone-iodine. The type, concentration, and presence of surfactants in iodine-containing solutions affect their bactericidal activity. Published data suggests that, in vitro, the rate of bacterial kill was greatest for aqueous iodine, followed by povidone-iodine antiseptic solution, and then povidone-iodinesurgical scrub solution.3l In a study of 294 pediatric surgical patients treated with a 5% povidone-iodine solution containing other inert substances, the rate of wound infection increased to 19%, compared to 8% for controls.32Further research revealed that use of a 1 % povidone-iodine solution without inert substances decreased the number of wound infections more than that of the control group. Effects of antiseptics on granulation tissue are not clear. Results yield conflicting information because of variations in the use of experimental methods and the concentrationsof solutions. Given currently available data, it is recommended that33 if antiseptics must be used, they should be used only in contaminated wounds in which delayed healing will result if not used, the antiseptic be properly diluted so that bactericidal activity will be retained without producing undue tissue injury, and the potential benefits of using the antiseptic outweigh the proven and potential harm to the healing wound.

Current Research on Wound Healing

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ransforming growth factor beta, vaccinia growth factor, platelet derived growth factor, epidermal growth factor, and fibronectin are currently being investigated as factors that might enhance wound healing. The largest accumulation of research data exists for fibronectin. Studies have demonstrated that the topical application of fibronectin is effective in healing persistent corneal ulcers and venous leg ulcers.34Other animal and in vitro studies indicate that fibronectin interacts with platelets, neutrophils, monocytes, fibroblasts, endothelial 516

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cells, epidermal cells, and bacteria in one or more of the following ways: to promote cell adhesion, spreading, migration, chemotaxis, phagocytosis, matrix and basement membrane organization, and secretion of growth factors.35Use of fibronectin in an experimental wound also was found to increase wound-breaking strength by about 30%.36 Transforming growth factor beta, produced by platelets, lymphocytes, macrophages, osteoblasts, and transformed cells, accelerates the accumulation of total protein, collagen, and deoxyribonucleic acid (DNA), induces angiogenesis, and increases wound-breaking strength up to two weeks after wounding.37 Transforming growth factor alpha and vaccinia growth factor combined with silver sulfadiazine were used on second-degree animal burn wounds and were found to accelerate epidermal regeneration.38 Platelet derived growth factor, released during platelet aggregation, stimulates DNA synthesis, increases collagen deposition for up to two weeks, and is chemotactic (responds to chemical stimuli) and mitogenic (promotes mitosis) for fibr~blasts.~~ Epidermal growth factor promotes granulation tissue formation by increasing collagen content and encouraging neovascularization in a dosedependent manner.4O Continued research on fibronectin and the growth factors briefly reviewed here is likely to elucidate the conditions and types of wounds for which they are best suited. In the future, perioperative nurses may be responsible for the topical application of one or more of these biological materials before final wound closure with staples, tape, or sutures. Preliminary evidence suggests that some of these materials more rapidly increase the tensile strength of the wound, which may permit more frequent use of tape closures or allow for the earlier removal of staple and skin sutures. Or, they may even eliminate the use of sutures or staples all together.

Conclusion

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ound healing is a necessary process that follows all surgical procedures in which the continuity of body tissue

is interrupted. Perioperative nurses are responsible for minimizing tissue trauma intraoperatively by handling tissue carefully to decrease damage to viable cells, tissue, and organs. An increased number of nonviable cells may delay healing while these cells undergo phagocytosis. Strict adherence to principles of sterility further decreases the risk of contamination that could result in surgical wound infection, delayed healing, more costly hospitalization, and increased risk to the physical and psychological well-being of the patient. Facts regarding the wound healing process, the systemic and local factors that affect healing, the proper application of surgical dressings, the use of antiseptics, and some of the current areas of wound healing research are all important tools in the perioperative nurse’s armamentarium. This ensures that contemporary nursing practice in the operating room is based on the latest scientifically derived information. 0 Notes 1. S Jacob, C Francone, W Lossow, Structure and Function in Man, fifth ed (Philadelphia: W B Saunders Co, 1982) 65-73. 2. P Wheater, H Burkitt, V Daniels, Functional Histology, second ed (New York Churchill Livingstone, 1987) 130-141. 3. S Gay, E Miller, Collagen in the Physiology and Pathology of Connective Tissue (Stuttgart: Gustav Fischer Verlag, 1978) 48-51, 75-79. 4. E Peacock, Wound Repair, third ed, E Peacock, Jr, ed (Philadelphia:W B Saunders, 1984) 1-14, 19. 5. T Irvin, Wound Healing: Principres and Practice (London: Chapman and Hall, 1981) 25-43. 6. Peacock, Wound Repair, 38-55. 7. R Edlich et al, “Technical factors in wound management,” in Fundamentals of Wound Management, ed T Hunt, J Dunphy (New York AppletonCentury-Crofts, 1979) 364-454. 8. T Krizek, M Robson, E Kho, “Bacterial growth and skin graft,” in Surgical Forum Proceedings for the 23rd Annual Sessions of the Forum on Fundamental Surgical Problems, 53rd Clinical Congress of the American College of Surgeons vol 18 (Chicago: American College of Surgeons, 1967) 5 18-519. 9. N Hugo et al, “The effect of primary wounding on the tensile strength of secondary wounds,” Surgery, Gynecology, and Obstetrics 131 (September 1970) 5 16518; J Madden, E Peacock, Jr, “Studies on the biology of collagen during wound healing,” Surgery 64 (July 1968) 288-294.

10. Peacock, Wound Rtpair, 1-120; Irvin, Wound Healing: Principles and Practice, 8-11. 11. S Westaby, “Fundamentals of wound healing,” Wound Care, (St Louis: C: V Mosby Co, 1986) 1314. 12. Peacock, Wound Repair, 12. 13. Wheater, Burkitt, Daniels, Functional H i s t ~ l ~ g y , 38-43, 160. 14. T Hunt, W Van Winkle, Jr, “Normal repair,” in Fundamentals of Wound Management, ed T Hunt, J Dunphy (New York: Appleton-Century-Crofts, 1979) 2-67. 15. Peacock, Wound Repair, 102-140. 16. Westaby, Wound Care, 49. 17. G Majno et al, “Conlraction of granulation tissue in vitro: Similarity to smooth muscle,” Science 173 (AUg 6, 1971) 548-550. 18. J Rabkin, T Hunt, “Local heat increases blood flow and oxygen tension in wounds,” Archives of Surgery 122 (February 1987) 221-225. 19. J Davis, T Hunt, Problem Wound.;: The Role of Oxygen (New York City; Elsevier, 1987) 1-16. 20. P Brachman et al, “Nosocomial surgical infections: Incidence and cost,” Surgical Clinics of North America 60 (February 1980) 15-25. 2 1. J Burke, “Infection,” in Fundamentab of Wound Management, ed T Hunt, J Dunphy (New York: Appleton-Century-Crofts, 1979) 170-240. 22. P Cruse, R Foord, “The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds,” Surgical Clinics of North America 60 (February 1980) 27-40. 23. D Sowa et al, “Effects of thermal knives on wound healing,” Obstetrics and Gynecology 66 (September 1985) 436-439. 24. W Eaglstein et al, “Optimal use of an occlusive dressing to enhance healing,” Archives of Dermatology 124 (March 1988) 392-395. 25. D Rovee et al, “Effect of local wound environment on epidermal healing,” in Epidermal Wound Healing, ed H Maibach, D Rovee (Chicago: Year Book Medical Publishers, Inc, 1972) 159-181. 26. J Finley, Practical Wound Management: A Manual of Dressings (Chicago: Year Book Medical Publishers, Inc, 1981) 11-22. 27. Eaglstein et al, “Optimal use of an occlusive dressing to enhance healing,” 392-395. 28. Ibid. 29. S Brennan, M Foster, D Leaper, “Antiseptic toxicity in wounds healin,g by secondary intention,” Journal of Hospital Infection 8 (November 1986) 263267. 30. S Brennan, D Leaper, “The effect of antiseptics on the healing wound: A study using the rabbit ear chamber,” British Journal sfsurgery 72 (October 1985) 780-782. 31. G Rodeheaver et al, “Bactericidal activity and 517

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toxicity of iodine-containing solutions in wounds,” Archives of Surgery 117 (February 1982) 181-186. 32. J Viljanto, “Disinfection of surgical wounds without inhibition of normal wound healing,” Archives of Surgery 115 (March 1980) 253-256. 33. D Leaper, S Cameron, J Lancaster, “Antiseptic solutions,” Community Outlook 83 (April 1987) 30, 32, 34. 34. T Nishida, S Nakagawa, R Manabe, “Clinical evaluation of fibronectin eyedropson epithelial disorders after herpetic keratitis,” Ophthamology 92 (February 1985) 213-216; A Wysocki et al, “Topical fibronectin therapy for treatment of a patient with chronic stasis ulcers,” Archives of Dermatology 124 (February 1988) 175-177. 35. F Grinnell, “Fibronectin and wound healing,” Journal of Cellular Biochemistry 26 no 2 (1984) 107116. 36. P Falcone et al, “The effect of exogenous fibronectin on wound breaking strength,” Plastic and Reconstructive Surgery 74 (December 1984) 809-812. 37. V Falagna et al, “Transforming growth factor beta: Selective increase in glycosaminoglycan synthesis by cultures of fibroblasts from patients with progressive systemicsclerosis,” Journal of InvestigativeDermatology 89 (July 1987) 100-104;A Roberts et al, “Transforming growth factor type beta: Rapid induction of fibrosis and angiogenesis in vivo and stimulation of collagen formation in vitro,” Proceedings of the National Academy of Sciences, USA 83 (June 1986)4167-4171; D Cromack et al, “Transforming growth factor beta levels in rat wound chambers,” Journal of Surgical Research 42 (June 1987) 622-628; M Sporn et al, “Polypeptide transforming growth factors isolated from bovine sources and used for wound healing in vivo,” Science 219 (March 18, 1983) 1329-1331; T Mustoe et al, “Accelerated healing of incisional wounds in rats induced by transforming growth factor beta,” Science 237 (Sept 11, 1987) 1333-1336. 38. G Schultz et al, “Epithelial wound healing enhanced by transforming growth factor alpha and vaccinia growth factor,” Science 235 (Jan 16, 1987) 350-352. 39. K Savage et al, “Growth factor on cell division and glycosaminoglycan synthesis by human skin and scar fibroblasts,” Journal of Investigative Dermatology 89 (July 1987) 93-99; S Lynch et al, “Role of plateletderived growth factor in wound healing: Synergistic effects with other growth factors,” Proceedings of the National Academy of Sciences, USA 84 (November 1987) 7696-7700. 48. A Buckley et al, “Epidermal growth factor increases granulation tissue formation dose dependently,” Journal of Surgical Research 43 (October 1987) 322-328.

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Health Officials Discuss Screening for HTLV-I The US Food and Drug Administration (FDA) held a meeting Sept 15, 1988, to discuss the human T-lymphotrophic virus type I (HTLV-I) before approving screening tests for the virus. At the meeting, blood bank administrators and US health officials were most concerned about not screening blood. The virus, which is a member of the acquired immune deficiency syndrome (AIDS) family, can exist in the human body for decades without causing disease. Scientists believe that only 1%to 2% of carriers will ever develop related disorders, such as leukemia. Despite these statistics, blood bank administrators plan to use the screening test to keep the HTLV-I out of their blood supplies, provided it is approved by the FDA as expected. The biggest problem is notifying donors if tests are positive. Participants in the meeting did not know what sexual precautions to recommend, nor what to tell women about pregnancy. Another problem is that tests cannot distinguish HTLV-I from HTLV-11, which has not been linked to any disease. According to a report in the Oct 7, 1988, issue of American Medical News, there also was much discussion of a look-back program. Most blood banks will begin such a program, which means that when blood is found to test positive for HTLV-I, all recipients of that blood will be checked for a HTLV-I-positive test. Some participants did not see the need to follow up with transfusion recipients unless there was a full-scale public health initiative to prevent the spread of the virus. The incubation period for HTLV-I is so long that a look-back may mean contacting people who received blood 20 or more years ago.

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bxamination HOMESTUDYPROGRAM

1. The skin is the largest organ of the body a) true b) false 2. The skin receives what amount of the circulating blood volume? a) one eighth b) one sixth c) one fourth d) one half 3. The major structural component of the skin is a) capillaries b) keratinized cells c) nerves d) collagen 4. The skin is characterized by how many major layers? a) two b) three c) four d) five 5. A wound is any interruption in the continuity of body tissue a) true b) false 6. The basic difference between chronic, traumatic, and surgical wounds is 1. surgical wounds close by primary intention 2. tissue loss 3. traumatic wounds have less tissue loss than chronic wounds 4. chronic wounds close by secondary intention c) 2, 3, and 4 a) 2 only b) 1 ,2 ,a n d3 d) 1,2,a nd4 520

7. Wounds that are the most resistant to infection

8.

9.

10.

11.

12.

are primarily healing wounds that are a) sutured b) stapled c) taped d) glued Which type of wound closure is recognized by its beefy red appearance? a) primary intention b) delayed primary intention c) secondary intention d) tertiary intention Which of the stages of wound healing at the cellular level begins with the surgical incision ? a) inflammation b) destructive c) proliferation d) maturation Epithelization, neovascularization, and collagen synthesis occur during which stage of healing? a) inflammation b) destructive c) proliferation d) maturation Collagen remodeling occurs in which stage of healing? a) inflammation b) destructive c) proliferation d) maturation Most wounds fully recover their original nonwounded tensile strength a) true b) false

FEBRUARY 1989, VOL. 49, NO 2

LORN JOURNAL

13. Which of the following systemic factors does not affect wound healing? a) skin preparation b) nutritional status c) shock d) blood oxygen tension 14. In surgeries exceeding three hours, occurring at night, or done on an emergency basis, wound infections increase a) twofold b) twofold to threefold c) threefold to fourfold d) fourfold 15. Preoperative preparation of the operative site has been found to affect incidence of infection, with the lowest incidence of infection in patients who have a) not been shaved or clipped b) been shaved with an electric razor c) had hair removed with clippers d) been shaved with a straight razor 16. Which of the following incision-making types of instruments produces the least damage to epithelial tissue? a) electrosurgical scalpel b) hemostatic scalpel c) carbon dioxide laser d) standard steel scalpel 17. In considering dressing materials for a wound, the nurse should be aware that a dry environment promotes the best epithelial migration and protects the wound from invading microorganisms a) true b) false 18. Which of the following statements about antiseptics is true? a) the routine use of antiseptics on all surgical wounds is good practice b) antiseptics produce tissue injury when applied to the exposed dermis c) antiseptics must be used in all contaminated wounds d) the antiseptic that has been shown to kill the most bacteria is povidone-iodine surgical scrub solution 19. The purpose of a single-layer occlusive polyurethrane dressing is to produce 521

epithelization of superficial wounds faster than air-exposed wounds a) true b) false 20. The purpose of the intermediate layer in a three-layer dressing is to provide a cushiontype effect over the wound a) true b) false Professional nurses are invited to submit manuscriptsfor the home study program. Manuscripts or queries should be sent to the Editor, AORN Journal 10170 E Mississippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal papers submitted for home study programs should not have been previously published or submitted simultaneously to any other publication.

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Thoroughly tested and documented For more informatiton, call Biodynamics at 713-862-6622or write: Biodynamics 6611 Portwest Drive, #190 Houston, Texas 77024

AORN JOURNAL

'ERRUARY 1989, VOL. 49, NO 2

Answer Sheet SURGICAL WOUNDHEALING

P

lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, C O 80231

Mark only one answer per question 1 2 3

'The deadline for this program is Aug 3 1, 1989.

4

1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. '4. Record the time required to complete the program 5. Enclose fee: Members $5; Nonmembers $12.

5 6

7 8 9

Name Address

10

City

11

;State Zip Session # 5472 Event # 845004

12

Program offered February 1989

13

,40RN (ID) #

14

RN license and state Florida license #

15 (Required for Florida CE Credit)

Kf nonmember, please provide Social Security #

16

17

Fee enclosed

or bill the credit card indicated

[IMaster Card

0 Visa

Card # Expiration date

18 19 20

Signature (for credit card authorization)

523

FEBRUARY 1989, VOL. 49, N O 2

AORN JOURNAL

Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5.

1. Objectives. To what extent were the following objectives of this home study program achieved ? (1) Discuss the physiology of the skin. (2) State the etiology of wounds. ( 3 ) Identify the stages of wound healing. (4) Describe factors affecting healing. ( 5 ) Identify basic dressing techniques, including the use of antiseptics.

(Low)

(High)

(1) (1) (1) (1)

(2) (2) (2) (2)

(3) (3) (3) (3)

(4) (4) (4) (4)

(5) (5) (5) (5)

(1)

(2)

(3)

(4)

(5)

2. Content. To what extent: (1) Did this article increase your knowledge of the subject matter? ( 2 ) Was the content clear and organized? ( 3 ) Did this article facilitate learning? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives?

(1) (1) (1) (1)

(2) (2) (2) (2)

(3) (3) (3) (3)

(4) (4) (4) (4)

(5) (5) (5) (5)

(1)

(2)

(3)

(4)

(5)

3. Test guestiodanswers. To what extent: (1) Were they reflective of the content? (2) Were they easy to understand? ( 3 ) Did they address important points?

(1) (1)

(2) (2) (2)

(3) (3) (3)

(4)

(5) (5) (5)

(1)

(4) (4)

4. Which other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s):

Author names and addresses:

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