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Infection prevention in surgical patients
with abdominal wounds Doris Appiagyei Agyare & Manisha Udash
2018 Laurea
2
Laurea University of Applied Sciences
Infection prevention in surgical patients
with abdominal wounds
Doris Appiagyei Agyare
Manisha Udash Degree Programme in Nursing Bachelor’s Thesis November 2018
3
Laurea University of Applied Sciences Abstract
Degree Programme in Nursing
Bachelor’s Thesis
Doris Appiagyei Agyare & Manisha Udash
Infection prevention in surgical patients with abdominal wounds
Year 2018 Pages 48
Surgical site infections (SSIs) are one of the major common adverse events that occur with
hospitalized surgical patients. The incidence of SSI after a surgical procedure is highly varia-
ble depending on the type of surgery being done and the underlying risk factors of the pa-
tient. Surgical site infection can cause longer stays in the hospital and additional surgery
sometimes causing longer queues for incoming patients, financial loss to families and to the
country as a whole.
Infection control measures should be applied from the beginning of admission of the patient
to the hospital, preoperative phase, intraoperative and postoperative phase. Nurses, sur-
geons, ward doctors and cleaning personnel play a major role in prevention of infection as
they deal with patients.
The study method was qualitative and the data was collected by interviewing four registered
nurses in the gastrointestinal surgical ward. Four main categories were formed from the data
by using inductive content analysis which are Observant daily wound care, Considering risks,
Educating patients and Follow-up of the procedures.
The findings reveal that the process nurses follow to prevent infection during postoperative
care is also connected to the preoperative phase. All the answers given really showed that
the nurse’s knowledge about abdominal wound infection is deep due to their experiences.
Basic knowledge of aseptic techniques and its applications are fundamental ways of prevent-
ing surgical site infection from the onset.
Keywords: Abdominal wound, infection prevention, surgical patients, nursing intervention,
surgical site infection (SSIs)
4
Table of Contents 1 Introduction .............................................................................................. 5
2 Surgical patients ......................................................................................... 5
2.1 Patients with abdominal surgery ........................................................... 7
2.2 Nursing intervention in abdominal surgery .............................................. 7
3 Abdominal surgery ...................................................................................... 9
3.1 Pre-operative phase ......................................................................... 10
3.2 Intra-operative phase ....................................................................... 11
3.3 Post-operative phase ........................................................................ 11
4 Surgical abdominal wound ........................................................................... 12
5 Surgical infection ...................................................................................... 13
5.1 Infection risk factors ........................................................................ 16
5.2 Infection prevention ........................................................................ 17
5.3 Improving infection prevention ........................................................... 18
6 Research question and purpose of the study ................................................... 19
7 Thesis research method ............................................................................. 20
7.1 Data collection process ..................................................................... 20
7.2 Data collection ................................................................................ 22
7.3 Data analysis .................................................................................. 23
8 Findings .................................................................................................. 26
8.1 Observant daily wound care ............................................................... 27
8.2 Considering risks ............................................................................. 27
8.3 Educating Patients ........................................................................... 28
8.4 Follow-up of the procedures after wound care ....................................... 29
9 Discussions .............................................................................................. 30
9.1 Discussion of the findings .................................................................. 30
9.2 Ethical considerations of the thesis ..................................................... 31
9.3 Trustworthiness of the thesis ............................................................. 32
9.4 Conclusions and recommendations ...................................................... 33
References ................................................................................................... 35
Table ........................................................................................................... 40
Figures ......................................................................................................... 41
Appendices ................................................................................................... 42
5
1 Introduction
Surgical site infection has become one of the most leading cause of hospitalized postoperative
patients. It is one the most widely concerned issues that surgical patients have been facing
and it has remained a major source of illness in surgical patients. Infection occurs at the op-
erated part of the body. And it arises after 30 days of the surgery or up to 1 year in patients
receiving implants affecting deep tissue at operation site. The infection can be superficial,
involving the skin or tissues under the skin or organs. The chances of SSI can be as high as 20%
depending on the different types of the procedure taken place during the surgery. According
to Burke (2003, 651–656) surgical site infections (SSIs) are considered to be the second most
common cause of nosocomial infections.
It is important that nurses try to prevent infection in abdominal wound surgery patients and
during the healing process. Informants of this thesis are registered nurses, who have had ex-
periences with post-operative abdominal wound infection patients. The thesis will focus on
nurses’ interventions and guidance with such patients; diagnosis, plan, evaluation and imple-
mentation. The findings might be helpful information for future nurses and patients as well.
According to the Annual epidemiological report for 2014, 18 364 SSIs were reported from a
total of 967 191 surgical procedures and percentage of SSIs per 100 surgical procedures varied
from 0.6% to 9.5% depending on the type of procedure. SSI can require longer hospital stays
and additional surgery causing longer queue for incoming patients, financial loss to families
and the country as a whole. Surgical site infections, is one of the side effects that occurs
after a patient undergoes for surgery (Seltzer et al., 2002).
Basic knowledge of aseptic techniques and its applications are the fundamental ways of pre-
venting surgical site infection from the onset. The purpose of the thesis is to describe what
nurses do to prevent infections in surgical patients with abdominal wounds. Primary concern
in healthcare today is the prevention of infection.
2 Surgical patients
A surgical patient can be defined as an acute sick person who might have a life-threatening
situation in most cases or vice versa. A surgery can be performed either on the level of urgen-
cy, risk or a purpose. A level of urgency is the situation whereby a quick surgery is done to
control or reverse life-threatening incident or to preserve function of life. Any delay in urgen-
cy surgery could be catastrophic and might be also be irreversible. It normally requires obser-
vation within 24-74 hours. Example of urgency cases can be surgery to repair gunshot wound,
control of haemorrhage. Urgent appendectomy is also an example. None withstanding, a sur-
gery can also be conducted at both patient and surgeon convenient time mostly depending on
6
the patient’s medical health condition a day before or some minutes before the surgery is
done. If it is not seen as a life-threatening condition, it is rather performed to enhance pa-
tient’s well-being or quality of life.
All the same, not performing the surgery would definitely not be any alarming repercussions
rather than performing the surgery and putting the life of the patient at risk. For example, a
hip-replacement surgery can be postponed, removal of uterus due to severe menstrual cramps
etc (Schuster at el., 2009). Furthermore, a surgery can be done on purpose not because the
patient has any medical problems but it is done due to patient’s preference in order to im-
prove his or her appearance. Examples can be repair of scars from burns, circumcision, and
plastic surgery to alter a perfect body shape. After preliminary assessments, patients are
given anaesthetic medications for sedation before being transported to the OR. ASA monitors
are used throughout the surgery with cardiorespiratory end-points documented at 5-min in-
tervals (Arain et al., 2004)
A surgical patient can be put into two categories: Outpatient or Inpatient.
An outpatient is a patient, who is not hospitalized overnight but goes to hospital or any health
care centre for treatment whether the situation is an emergency or vice versa and returns
home after been treated that same very day. It can also be check-ups. An out-patient is not
kept at the hospital for more than 24 hours. The patient’s information needs to recorded
even though there is not going to be any overnight stay. For example, a patient going for a
tooth extraction surgery, an arthroscopic knee washout, an opened wound closure etc. can be
classified as outpatients.
After discharge, a telephone follow-up (Quemby & Stocker, 2013). Nurses should have good
assessment skills and knowledge in caring for outpatients. Especially, obtaining good commu-
nication skills with patients, anaesthesiologists and surgeons. Nurses should be able to have
adapting competence as well since day surgery unit always have fast turnover of patients
(Voda, 2011).
An inpatient on the other hand is admitted at the hospital and stays overnight for a period of
days. Mostly inpatients require frequent monitoring during and after treatment. Since they
tend to have more demanding cases which might deteriorate at any given time so a close
medical observation should be kept on them to avoid further complications. They are dis-
charged after their conditions are stabilized and can manage on their own without any
healthcare worker being around them all the time. There are exceptional cases whereby pa-
tients stay overnight during admission but will not have an inpatient status. (Walker, 2002)
More importantly, the diagnosis, evaluation and the surgical care of the patient are mainly
the responsibilities of the surgeons. They make sure the patient undergoes preoperative as-
7
sessment. The assessment normally includes patient's chart and an independent diagnosis by
the surgeon in charge of the surgery (Plauntz, 2007). The operating surgeon discusses with the
patient or significant others concerning the type of the surgery, diagnosis and risks involved.
Re-evaluating the patient quickly prior to the operation is also the duty of the patient. Gain-
ing patients’ confidence, assuring help available and will be provided.
The evaluation and management of the surgical patient pre, intra and post phase is part of
the primary responsibility of the surgeon (Walker,2002). After the surgery is done, postopera-
tive notes should have the findings encountered during the surgery (Mohabir & Gurney, 2015).
Patient positioning plays a major role during the surgical operation even though some sur-
geons might have their own preferences. Good positioning also helps in prevention of pressure
sores O'Connell (2006).
2.1 Patients with abdominal surgery
Patients with abdominal surgery are considered as patients with abdomen problems whereby
an operative procedure, in which the abdominal cavity is opened, and surgeons repair dam-
aged, redundant or malignant tissue causing discomfort for the patient. The most common
ones are; inguinal hernia repair, exploratory laparotomy, appendectomy and laparoscopy.
Patients who have undergone abdominal surgery have incisions that need to be checked on a
daily basis to foresee an oncoming surgical site infection (Strik et al., 2016).
They are at a higher risk of wound dehiscence (direct wound inspection) especially when the
anterior wall is not closable, the risk of anastomotic leak and enter atmospheric fistula be-
come high and abdominal compartment syndrome (bladder pressure monitoring). Patients
with abdominal surgery can also be classified as ICU patients since they need constant moni-
toring.
Possible complications patients with abdominal can encounter are; excessive bleeding, wound
infection, incisional hernia, recurrent gastric ulcer, chronic diarrhea, malnutrition; pain,
swelling, redness, drainage or bleeding in the surgical area; headache, muscle aches, dizzi-
ness or fever; increased abdominal pain or swelling, constipation, nausea or vomiting; rectal
bleeding or black stools Piper & Kaplan (2016).
2.2 Nursing intervention in abdominal surgery
The role of the nurse is to intervene for patients by promoting and maintaining health, pre-
vention of illness /infection, aim to support, treat patient as a fellow human being, listening
and empathizing with patients and last but not the least, alleviating suffering (Schubert et
al., 2008). A nurse enlightens the patient on the type surgery he/she is going for and also
prepares the patient mentally, emotionally and physically to reduce stress and anxiety. Nurs-
es should be able to identify surgical site infection mostly caused by previous cases. If a cath-
8
eter or a cannula is inserted during the surgery, it is the nurses’ responsibility to remove it
when it is no longer needed since it can cause infection. Cannula should be changed into a
different position if the patient will be needing more fluids.
Constant observations should be carried out on patients when they are transferred from the
theatre to the recovery room. Nurses keep close eyes by constantly monitoring patients’
blood pressure, temperature, pulse, breathing and oxygen levels. During the course of this,
the wound dressing is also checked to see if there is any excessive bleeding. The oxygen
mask is not removed until the effects of the anesthetic are worn off. (Burke 2003; Sessler
2006). Patients are transferred back to the ward after some minutes or hours depending on
how consciousness level will be. All patients are assessed for severity of pain using either a
verbal rating scale or a visual analog scale.
Pain control is also essential since some patients may end having the Patient Controlled Anal-
gesia pump (PCA). This contains a strong painkiller and it is controlled by the patient. Once
the patient presses the hand-held button, the set amount of painkiller from the syringe goes
direct into the vein in your arm or hand. The whole procedure is regulated in a way that, the
patient cannot get over dose even if the patient wants to and it also controlled by the nurses
frequently. There are other choices like tablets, or liquid to swallow to control any pain the
patients may have. Alleviating patients’ pain is a paramount importance during the nursing
interventions (Walker, 2003). Deep Vein Thrombosis (DVT) is likely to occur after surgery due
to blood becoming stagnant in veins because of patients’ capability of moving around has
become limited in the ward. Because of this, surgeons prescribe DVT drugs to prevent blood
clot (Saltissi et al., 1999).
Also, educating patients and their significant others is also another way of minimizing surgical
site infections. The only procedure for nurses is to try their possible best to nurse them for
quicker recovery before discharge since some patients will not follow the verbal and written
information given to them to follow once discharged; patients going home should have re-
sponsible escort (Quemby & Stocker, 2013). Furthermore, some patients do not understand
the importance of mobility and how to take care of their wounds after surgery so nurses go
extra mile to educate patients even more and at the same motivate them on how to take
good care of their health. Well, there are cases whereby patients upon understanding all the
in-formation said and written, they still think it is a nurse responsibility to take care of them
(Kalisch, 2006).
Furthermore, hygiene is one of the key factors that helps in prevention of infection. The
nurses help the patients to have a wash or shower if the patient is not mobile enough to do it.
The wound should be kept dry with a clean dressing at all the time (Wysocki, 1989). Before
the patient is being discharged, the stiches are removed by nurses. If there may be a need if
9
nutritional support, the nurse calls in the nutritionist for the patient. Direct communication
with the significant others is sometimes established to have some realistic goals of care. Be-
fore the patient leaves the hospital, nurses make sure the patient fully understands the sur-
gery that was done and the simple instructions to follow at home to avoid complication or
infections. For example, avoiding lifting heavy objects, how to take prescribed drugs if there
is any.
3 Abdominal surgery
Abdominal part of the body widely includes stomach, small intestine, large intestine, liver,
gallbladder, pancreas, and spleen and abdominal surgery usually covers surgical procedures
that includes abdomen. Different part of abdominal surgery depends upon the patient’s situa-
tion for example, infection, obstruction, tumors, inflammatory bowel disease or traumatic
injury or natural disease. Most of the common abdominal surgeries are as inguinal hernia sur-
gery, abdominal exploration surgery, appendectomy or surgery for inflammatory bowel dis-
ease, which may consist of removing all or part of the small or large intestine (Florida Hospi-
tal, n.d.)
Appendectomy is the most common surgery which involves removing of appendix. Inflamma-
tion of the appendix is known as appendicitis in this situation, appendectomy procedure is
performed. Appendectomy can also be sometimes performed as another type of abdominal
procedure. In a situation when appendectomy is performed where appendix is already rup-
tured, a longer hospital stay is needed whereas, if the appendix is not ruptured, it is quickly
recovered.
‘‘Laparotomy is performed to explore abdominal called as exploratory laparotomy when clini-
cal diagnostic methods are unable to find the cause of various abdominal symptoms. It is per-
formed in patients with acute abdominal pain that may be due to some abdominal trauma.
Additional surgery might be performed after finding the cause from this procedure (Vikram
Kate, 2017).
Laparoscopy is the most common less invasive method used or preferred for diagnosing differ-
ent intra-abdominal diseases. In this procedure, several small holes are made surgically in the
wall of the abdominal, where tubes are inserted into the holes. A small camera is fixed in one
of these tubes to look through the abdominal cavity without making big incision. This method
is often used when performing a cholecystectomy, or gallbladder removal. Decreased post-
operative pain, reduced morbidity and short hospital stay are most common advantage of
using this method.
10
3.1 Pre-operative phase
This is the phase when a patient has decided to go for the surgery with all consent forms
signed. It begins from the ward to anesthesia room and to the operating room. During this
phase, all kind of assessment are done according to the age of the patient as young and older
aged people are at more risk for having complications during the surgery. Some of the as-
sessment done during this phase are as patients’ nutritional status, fluid and electrolyte sta-
tus to prevent hypovolemia during surgery.
Similarly, presence of infection, other health problems related to cardio, respiratory, renal,
neurologic, hematologic, etc. The use of medication to prevent the life-threatening situation
during and after the surgery and lastly lifestyles like habit of smoking to be prepared before-
hand. Sometimes this phase can be extremely short in case of acute trauma and can be long
preparation in a case a patient needs to fast or lose weight (Jennifer Whitlock, updated
2018).
Pre-operative phase also helps a patient to overcome the anxiety and stress for oncoming
surgery which is called as Preoperative anxiety. Nonmedical interventions such as hypnosis
and guided imagery has been shown to reduce pain, anxiety, and length of stay in patients
undergoing diverse surgical procedures (Antall 2004; Halpin 2002; Lambert 1996). Example,
deep breathing, turning, splinting, and purse- lip breathing exercises and this can be very
useful for preventing complication like pneumonia and respiratory problems. This phase also
includes process of obtaining consent from the patient after informing and explaining the
details of the surgery to be performed and the prescribed medications like tranquilizers, sed-
atives, analgesics, and anticholinergics are also prepared (Clinical guidelines, 2008).
Surgical site infection can also be prevented starting from this phase. According to the Clini-
cal guidelines by National Institute for Health and care Excellence, 2008, these are the pro-
cedures needs to be followed during this phase: Patients are advised about pre-operative
shower or bath using soap either the day before or on the day of the surgery. Likewise, re-
moving hair regularly can be a risk for getting SSI (Surgical site infection) and if the hair
needs to be removed for the surgery, it can be done by using electric clippers but not with
razer as it increases the chance for infection. Patient’s theatre wear needs to be appropriate
for easy access according to the patient’s comfort and dignity, and staff’s theatre wear needs
to be non-sterile where the operation is undertaken. Removing any kind of hand jewellery or
nail polish, avoiding the use of mechanical bowel preparation regularly are also very im-
portant for prevention infection.
Lastly, use of Antibiotic prophylaxis is done according the type of surgery performed, howev-
er, informing patients before the operation, whenever possible, if they will need antibiotic
11
prophylaxis, and afterwards if they can be given antibiotics during their operation is always
done in the pre-operative phase.
3.2 Intra-operative phase
This is the second phase of surgery and where the surgery is performed; it starts when the
patient is transferred to the operating room till the patient is re-transferred to the recovery
room after the operation is done. The surgical team consists of surgeon, assistant surgeon,
anesthesiologist, holding area nurse, circulating nurse and scrub nurse. The verification of the
checklist, prescribed medications, consent form and various preparation including exact posi-
tion of the patients and skin preparation are usually done the surgical team. Surgical sepsis is
also maintained highly in this phase which includes health of the surgical team, surgical attire
and surgical scrub.
The role of the circulating nurse is to monitor the patient’s well-being in collaboration with
surgeon and anesthesiologist, providing solutions, supplies and instruments, and documenting
the progress of the surgery. Likewise, scrub nurse assists the surgeon by handling instruments
and supplies to the surgeon while maintaining surgical sepsis. (Daisy Jane Antipuesto RN MN,
2011).
The first and most important part for preventing SSI in this phase is, hand decontamination,
surgical team need to wash their hand using aqueous antiseptic surgical solution ensuring that
hand are visibly clean (NICE Clinical Guidelines, 2008) Iodophor-impregnated drape is usually
recommended to be used to reduce surgical site infection unless patient has an iodine allergy.
Sterile gowns and gloves are other most essential part for preventing infection. Similarly, skin
preparation must be prepared with an antiseptic and wound irrigation and intracavity lavage
cannot be used.
Lastly, before wound closure the operated part of the skin should be re-disinfected. Topical
cefotaxime should not be used in abdominal surgery to reduce the risk of SSI. At the end of
the operation, the incisions should be covered with appropriate dressing (Clinical guideline,
2008).
3.3 Post-operative phase
The post-operative phase is the final phase which starts from the time of admission of patient
in the recovery room to the follow up evaluation (ward). The care given during this phase
mainly focuses on the patient’s physiological health and post-surgical recovery. The ABCS,
airway, breathing, and circulation, oxygen saturation and ventilation, vital signs and level of
consciousness are firstly assessed. This is the phase where Nursing intervention is followed up
and some of the assessment may include ensuring hydration, monitoring urination or bowel
12
movements, assisting with mobility, providing appropriate nutrition, managing pain, prevent-
ing infection, etc. (Jennifer Whitlock, updated 2018).
The greatest complication that occurs during this phase is the wound healing process. There
are cases wound takes longer depending on the type of surgery performed. According to Got-
trup F 2004, oxygen therapy is important in relation to both healing and resistance to infec-
tions. However, the most severe postoperative complication can be the development of pres-
sure ulcers, or bedsores. These ulcers grow at pressure points in patients who are incapable
or unwilling (because of pain) to shift their positions in bed; early signs of their development
can be present within two hours of pressure being applied (Bansal, 2005).
In order to prevent SSI in this phase, all preventing measures should be taken during the first
two phases. Besides this, some of the examples of other measures are as using an aseptic
non-touch technique for wound dressing; sterile saline for wound cleansing up to 48 hours
after surgery; advising patient to safely shower 48hours after surgery and etc. Antibiotic
treatment of surgical site infection is also common when surgical site infection is suspected
and needs of giving antibiotic that covers the likely causative organisms.
4 Surgical abdominal wound
A cut or incision made by scalpel in the skin during surgery and sometimes drain place during
surgery is also known as surgical wound. The size of the wound depends on the type of sur-
gery being performed. Surgical wounds are usually closed by sutures, staples or tapes but
sometimes left open for healing depending on the type of surgery (Wysocki, 1989).
The different types of surgical wound have been classified into four. In Class I, the surgical
wound is clean and shows no sign of infection or inflammation. This type of surgery includes
laparoscopic surgery involving skin, eyes, or vascular surgeries. Class II is a clean contaminat-
ed wound that shows higher risk of infections because of its locations like gastro-intestinal,
respiratory or genitourinary tracts.
Wounds are considered as Class III when outside object comes in contact with the skin causing
higher risk of infection. Class III can also be de-scribed as an open, traumatic wound and some
examples are gunshot, blade or other sharp objects causing contamination to the surgical
wound. Class IV (old traumatic wound containing dead tissue) is considered as dirty contami-
nated wounds that have been exposed to pus or faecal matter.
Wound closure is a major key factor during surgical operation because when a wound is closed
properly, there is a low risk of outside bacteria entering it to cause infection. Wysocki cate-
gorized wound closure into three types; “Primary closure, Secondary closure and delayed
closure”. Primary closure also known as healing by primary intention is the quickest closure
with minimal scars. It is clean has low risk of infection. Often, all the layers are closed and
13
patients are not bothered by wound care specialist. Secondary closure which can also be
called secondary intention has deep layers and the healing comes from within. More time is
needed during the secondary wound closure and comes up with more tissue loss. It normally
occurs in trauma and infection cases.
Lastly, delayed closure or healing by tertiary intention can be described as the combination
of primary and secondary whereby a wound specialist attention is required due to infection.
Delayed wound is not closed straight after a surgery has been done but it is left opened for
couple of days for inspection of infection before it is closed. A typical example of delayed
wound closure is dog bite.
According to Guo & DiPietro (2010), wound healing can be very complex with many factors
contributing to the overall healing process. Wound healing occurs as a series of overlapping
and often simultaneous stages and is the process whereby the continuity of the injured tissue
is restored. And in order for a wound to be healed; it has to pass through four phases which
are Hemostasis, Inflammation, Proliferative and Maturation. Hemostasis, is the first phase of
the healing process. During this phase, the first thing to do is to stop the wound from bleed-
ing. In other words, a” first aid” intervention is being practiced. The platelets come into con-
tact with collagen causing activation and aggregation. The thrombin therefore strengthens
the platelet clumps into a stable blood clot.
During the Inflammation phase which can also be called as defensive; it deals on destroying
the bacteria and clearing the debris causing thromboxane and decrease in blood loss. The
white blood cells leave while macrophages arrive to continue to clear the debris. This phase
normally lasts 4 to 6 days and is often associated with edema, reddening of the skin, heat and
pain. The Proliferative on the other hand focuses on filling and covering the wound. The
damaged area of the wound begins to rebuild with the help of the granulation tissues
(Wysocki, 1989).
Furthermore, the angiogenesis rebuilds the blood vessel and with the help of the collagen,
new blood vessels are able to grow. The Proliferative phase often lasts 4 to 24 days. The final
healing process of a wound is the Maturation phase. Here, the collagen reconstructs and tis-
sues mature with tensile strength. This phase begins from the 3rd week and it carries on to 9-
12 months before it heals depending on the type of wound (Tonnesen et al., 2000).
5 Surgical infection
According to Burke (2003, pp. 651–656)” surgical site infections (SSIs) are considered to be
the second most common cause of nosocomial infections. And can also, lead to longer stay in
the hospital causing long queue in admission and increase of health care costs. Statistics
about nosocomial urinary tract infections constituted 42% of the infections while surgical
14
wound infections 24%. Patients undergoing intra-abdominal and extra abdominal surgical op-
eration are bound to develop an SSI (Haley et al, 1985). Upon all the phenomenal precautions
in the use of surgical techniques and prophylactic antibiotics, surgical site infections still re-
main a significant cause of patient mortality and morbidity (Bratzler et al., 2005).
Surgical site infections (SSIs) are mostly acquired during the intraoperative and postoperative
phase. There are cases whereby it can also be acquired during the preoperative phase. It is
mostly common and inevitable in some cases. Since there are situations whereby the pa-
tient’s own body gets infected by contamination of the incision with microorganisms during
the intraoperative phase (endogenous bacteria). This makes patients tend to end up in the
intensive care unit (ITU) and in the high dependency unit (HDU) (Kirkland et al. 1999).
According to Nichols (1998) many factors such as length and type of surgery, the surgical
team, medical history of the patient, surgical instruments, or etc. contribute to perioperative
infection. Generally, surgical wound infection is caused by bacteria like staphylococcus and
pseudomonas and streptococcus. SSIs can also be caused in so many other ways by surgical
team, disregarded written surgical principles, use of unsterile surgical instruments, germs in
the air, operating environment (exogenous bacteria). Morbidity and mortality in postsurgical
care are the main results by surgical site infection (Young & Khada, 2014).
Emergency patients are prone to have SSIs due to fast preparation or shortage of surgical staff
because it is sometimes after the normal duty working hours. This can lead to insufficient
preparations such as a thorough sufficient skin preparation that is, washing the part of the
skin that needs to be operated on with chlorhexidine gluconate cleanser or any skin disinfect-
ant within the operating room. Generally, during those rush hours the main focus is being
based on how to save the patients’ life.
Longer explosion of the tissues during the intra phase can cause SSIs especially if the patient
is host risk factor. The ASA score helps in grading the patients’ going for surgery capability
status if they are at high risk. Chances of hypothermia occurring in the intra phase is very
high. The goal of antimicrobial prophylaxis is to prevent infection which is likely to occur
during the surgical operation procedures but methicillin-resistant staphylococcus aureus
(MRSA) is another bacterium which resists commonly used antibiotics causing slow wound
healing. Since it mostly causes mild infection on the skin, constant antibiotics should be ad-
ministered on the surgical site to prevent infection (Mangram et al., 1999).
Forasmuch as SSIs is bound to happen, it takes days before the manifestation on the skin but
it definitely shows signs. Any operated part of the skin which has been infected will show the
following signs and symptoms: swelling redness, fluctuation, turbid aspirate, pain, slow heal-
ing and hyperthermia (Wysocki, 1989).
15
Figure 1: Cross-section of abdominal wall depicting CDC classifications of surgical site infec-
tion. (Mangram et al 1999, p5)
16
According Owen & Stoessel (2008), surgical site infections normally take place within 30 days
after the surgery and has been categorized into 3, superficial, deep and organ incisional.
SUPERFICIAL INCISIONAL DEEP INCISIONAL ORGAN INCISIONAL
• Involves only the
skin, subcutaneous
tissue
• Creates pus
• Intentional reopen-
ing unless culture of
incision is negative
• Purulent drainage
• Isolation of organism
from tissue in inci-
sion
• Involves deep soft
tissue
• Occurs when there is
purulent drainage
• Radiologic exam
• Intentional reopen-
ing on its own or
from surgeons
• Involves any area of
the body such as
body organ or space
between organs
• Occurs 30 days after
the postoperative
phase or within 1
year if an implant is
present.
• Purulent drainage
• Organism isolation
from organs
Table 1: Types of surgical site infection
5.1 Infection risk factors
Risk of infection can be described as "the state in which an individual is at risk to be invaded
by an opportunistic or pathogenic agent (virus, fungus, bacteria, protozoa, or other parasite)
from endogenous or exogenous sources". The risk factors that may increase infection in the
hospital include; long stay in the hospital after surgical operation, the type and length of the
surgery performed on the surgical patient may have an impact, overuse of antibiotics, inci-
sions, surgical equipment and high-risk areas in the hospital such as ICU and HDU (Kirkland et
al.,1999).
17
The identification of risk factors contributes to the creation of SSI prevention strategies, thus
allowing health professionals to take actions that reduce complications resulting from infec-
tions and minimize SSI rates. There are four main factors which mostly influence the infection
rates in surgical wounds. They include, Patient variables, Preoperative preparation, In-
traoperative procedure and Postoperative care.
A good health condition plays a pivotal role during the three phases of surgery and helps the
patient to recover quickly with or without any infection contamination. But not all patients
are lucky to have good medical condition and as a result of that, they are already labelled as
risk factor and are also vulnerable to infections due to their endogenous. Their health status
can easily change instantly during preoperatively, intraoperatively and postoperatively phas-
es. Examples of such patients are; Peripheral vascular disease, Overweight, Diabetes mellitus,
Smoking, Cancer, Elderly patients, Medical problems, Chronic skin disease, Malnutrition, Im-
munosuppression, Radiation, Anaemia, Carrier state (e.g. chronic staphylococcus carriage)
(Pomposelli et al.1998; Johnson et al. 2006).
5.2 Infection prevention
Prevention of SSIs is very complex endeavor requiring all the multidisciplinary team with the
involvement of the patient as well sustained (Wysocki, 1989). Surgical site infection (SSI) dur-
ing the postoperative phase is very especially when the surgery performed was about laparot-
omy. Appropriate care during and after surgery helps prevent infections and contributes to
fast wound healing. Proper preoperative skin antisepsis reduces postoperative infection since
the skin can be the main source of bacterial that causes SSI. Before the perioperative phase,
previous infection should be treated. But diabetic patients should be put under control and
regular follow ups to have a good stable blood level.
Administration of prophylaxis antibiotics during preoperative phase of surgery before the in-
traoperative phase begins. The antimicrobial prophylaxis helps in preventing postoperative
infections. Clipping instead of shaving, stable normothermia, and oxygen supplementation
preoperatively, good closure of the incision are vital factors that contribute in prevention of
infection. Prophylaxis antibiotics can be used in any situation where there is a risk of contam-
ination or there is an expectation of an infection. Clean environment starting from the ward,
the operating room and to the recovery room plays a major role (Owen & Stoessel, 2008).
Strict aseptic techniques such as the surgeons and scrub nurses wearing clean surgical gowns
and headgear, washing their hands and forearms with sponges and brushes with the applica-
tion of antimicrobial soaps, iodine or chlorhexidine McHugh et al., Anesthetic technicians
must go sterile when administering epidural and spinal anesthesia, avoidance of unnecessary
excessive cautery during incision, changing of gloves (Chang et al 2010). When there is a hole
or too much stain of blood all contribute major factor in prevention of infections with the
18
limitation of activity that does not concern the operation and too much talking during the
intraoperative phase. Furthermore, good blood supply and fluids using a warmer if the surgery
will last more than an hour to avoid hypothermia and hyperglycemia (Sessler, 2006).
Isolation of infected patients from uninfected patients to a room of their own is very para-
mount since infection is known to be transferable from one patient to another. If possible,
infected patients should have their own nurses like it is done in the recovery room after sur-
gery. Patients who are infected can be put in the same room with patients who are host risk
of SSIs. The isolation helps healthy recover faster and enables early discharge and minimizes
hospital costs and long patients’ queues in the hospital.
Postsurgical wound care after abdominal surgery, after wound has been closed patients will
automatically go a random dressing change will be take place every two days. But the must
be protected from any possible contamination by sterile dressings for minimum of 24 hours
before it is changed. During this phase, proper aseptic techniques must be followed in order
not to contaminate or transfer any bacterial to the clean wound.
The right aseptic procedure is done by first washing the hands with soap, drying them com-
pletely before wearing the clean gloves. After the wound has been cleaned with gauze pad,
saline (a salt water solution) or a clean tap water, change gloves before applying the sterile
dressing such bandage or plaster. Because, during the dressing change, the gloves automati-
cally become dirty (Wysocki, 1989).
Wound dehiscence can be quite severe for the patient and it is also associated with a high
mortality rate. It happens due to poor tissue healing from malnutrition, obesity, anemia, in-
fection, premature removal of wound closure or stress on the unhealed incision such as strain-
ing or coughing. Thus, identification and appropriate management of the condition is key to
avoid infection. It can also be reduced by applying excellent surgical technique in each pa-
tient, prevention of pneumonia and wound infection. An excellent surgical team can also in
preventing SSIs. Significant others should avoid touching the operated part of the body when-
ever they visit the patient (Riou et al., 1999; Pavlidis et al, 2011).
In conclusion, surgical site infection can be prevented and managed by providing a clean envi-
ronment for patient, nurses and whole surgical team should following all the aseptic tech-
niques and good patient education before and after operation. All the prevention procedures
can easily be put into practice either in the hospital, nursing homes and even patients’ homes
as well.
5.3 Improving infection prevention
Patients have to be their own advocate in their own health care and think about their state of
health before and after being admitted to the hospital (Bodenheimer et al., 2002). Quality
19
initiative in the perioperative phase should be ultimate goal and without omitting any of the
aseptic techniques. Prophylactic antibiotics should be given within one hour prior to surgical
incision while normothermia is being given preoperatively. Compression stockings need to
worn in bed. Urinary catheter (flexible tube used to empty the bladder and urine in drainage
bag.
Also, it is used for measurement of urine output management of postoperative urinary reten-
tion however should be managed properly by removing it on day 3 to 6 as recommended to
avoid urinary tract infections (UTIs) unless the patient’s condition demands a longer stay.
Also, surgeons developing good closure techniques to avoid wound dehiscence is very im-
portant. Hair at the surgical site should be removed by depilatory methods and not with
blades (Page et al., 1993).
In providing a proper holistic care, patients themselves play a vital role in bettering care out-
comes. Obviously, the surgical patient is the primary holder of the bacteria and carries the
repercussion of the SSIs and should therefore be taught and guided on how to participate in
the prevention SSIs. Furthermore, patient self-care contributes a lot to quick recovery and
prevention of SSIs thus by having a good balance diet and daily activity since it helps with the
flow of internal oxygen. Smokers should quit smoking for couple of days to decrease the risk
of infection.
Postoperative wound care should be handled attentively. All the dressings for drainage and
closure should be checked closely to able to see any changes that is alarming in the post an-
esthetic care unit. More significance must be put on hand hygiene and strict asepsis during
changes. Monitoring of patients’ vital signs and keeping them warm as needed. Nurses should
carefully review postoperative plan with the patient and significant others to the level what
is written and said is understood.
Continuous education for whole surgical team (surgeons, nurses, anesthetists’ and clinical
support workers, patients and significant others) minimizes the risks of SSIs when recom-
mended measures are followed. Furthermore, follow up of all surgical wound patients espe-
cially patients who are host risk of SSIs for any possible postop infection to act upon as quick-
ly as possible if there is a rise of infection. According to Pavlidis, patients who are host risk
factors are already prone to infection and need more attention and special care to minimize
the risk of abdominal wound dehiscence occurrence.
6 Research question and purpose of the study
The purpose of the thesis is to describe what do nurses do to prevent infections in surgical
patients with abdominal wounds.
20
The research question of the thesis is “What do nurses do to prevent infections in surgical
patients with abdominal wounds?”
7 Thesis research method
Qualitative research is a type of scientific research that search for answers to a question,
systematically uses a predefined set of events to answer the question, gathers evidence, finds
conclusions that were not determined in advance, produces findings that are appropriate
beyond the direct limits of the study (Natasha Mack, Cynthia Woodsong, Kathleen M.
Macqueen, Greg guest, & Emily Namey, 2011). In this thesis the data was gathered by using
interview as the method. Qualitative interviews allow a researcher to naturally study the
individual lived experience of another (Brinkmann 2013, 47). The researcher also chooses the
concepts and how the data is collected, transcribed, analyzed and reported.
The number of participants in qualitative study is normally smaller compared to quantitative
study because quantitative aims for statistical generalization while qualitative deals with
finding solutions to past, present and future occurrence (Brinkmann 2013, 144). Therefore,
qualitative research method was the logical choice for this thesis as the purpose was to de-
scribe what nurses do to prevent infection in abdominal wounds. Qualitative research is nor-
mally analyzed with content analysis and it was used for this thesis. Inductive method deals
with the generation of new theory extracting from the data or looking at previously re-
searched situation from a different angle (Gabriel, 2013).
7.1 Data collection process
The data collection process began by first contacting the clinical teacher of the hospital
where the interview was conducted. The clinical teacher was contacted by the writers of the
thesis through email to get permission after the contract of the thesis was accepted by the
senior lecturer supervising the thesis. The writers of the thesis then proceeded with the writ-
ing of the thesis plan and after the plan was done, an abstract of the plan was sent to the
clinical teacher in June 2018 together with consent forms that needed to be filled and signed
by the writers of the thesis to get permission to do the interview at the hospital. The forms
were sent to the writers through email by the clinical teacher. It took about two months be-
fore a response came from the clinical teacher after the abstract of the thesis plan and the
consent forms were emailed.
21
In August 2018 permission was granted to conduct the interview and the contact information
of the interested participants were given to the writers of the thesis by the clinical teacher
for further communication. The participants willing to be part of the interview were first
contacted by the clinical teacher by briefing them about the thesis topic. The clinical teacher
helped to get four registered nurses from two different units. The interviewers’ main goal
was to know what nurses do to prevent infection in surgical patients with abdominal wounds.
Choosing the interview settings, structure, length, time, questions and way of recording were
also part of the planning. The interviewers and the interviewees fixed the time and place of
the interview together through email.
The participants were assured about the confidentiality and good ethical conduct of the writ-
ers in a covering letter (see Appendix 5). They were also assured about the confidentiality of
the interview and asked to sign consent form (Appendix 3) before interview. The interviews
took place in September 2018 and they were all approximately 30 minutes long. Both writers
of this thesis were present in every interview. During the interview session, the data was
collected by interviewing face-to-face four female registered nurses in a gastrointestinal unit,
two nurses from two different units. The participants were provided with the interview ques-
tions both in English and Finnish before the interview. The data collection process is demon-
strated in Figure 2.
Figure 2: Data collection process
22
7.2 Data collection
The method used in the thesis was a semi structured group interview. According to Powney
and Watts, an interview is a conversation between two or more people where one or more of
the participants takes the control for re-porting the substance of what is said. Qualitative
interview is normally used when researchers are keen to know people's experiences in the
past, language and communication, and culture and the society as whole (Brinkmann 2013,
47). With the nurses’ experiences and what they have been doing to prevent infection in sur-
gical patients with abdominal wounds will help the writers to get answers to the thesis topic.
This can demonstrate and help researchers to know about how a specific event did occur and
if there is a chance of the same thing occurring again. Individual interview is more effective
and flexible than group interviews. It also helps the interviewer to get more insight from the
topic being discussed (Chrzanowska, 2002). The interview was conducted in two separate
groups and it took about thirty minutes for each interview.
The participants in this study were four female registered nurses working in a unit of gastroin-
testinal surgery. The reason for choosing this target group was because nurses play an im-
portant role in the surgical patients with abdominal wounds. Participants were given free
time and good environment to be able to express their personal views based on their own
experiences. The participants chose to be interviewed at the hospital and the interviewers
agreed to it. As Marshall & Rossman (2006) also argue qualitative methods have three aspects:
Individual lived experience, society and culture, language and communication. The writers of
the thesis had also taken into consideration the language of communication both parties had
in common to be able to understand each other clearly during the interview without any mis-
understanding since the interviewees had Finnish as their first language and the interviewers
do not.
The interview took place in September 2018 and it was conducted at the hospital in a re-
served room (patient’s living room). The doors were locked to avoid disturbances during the
interview. The interviewees and the interviewers sat around a table facing each other. The
interviewers introduced themselves and briefed the interviewees about the thesis. Before the
interview began, the interviewees were asked to go through the printed questions again.
The interviews were recorded with one tape recorder and one of the writers’ just in case the
tape would not work. The recordings were loaded on both thesis writers’ computers for tran-
scribing them. The interviews were transcribed to be able to re-listen to them many times
and to make notes on the documents. Transcribing the data was done by the writers of this
thesis by listening to each interview recording and typing them down on separate files by
using Microsoft Word. It took about six hours depending on the length of the answers and lan-
guage, since some of the interviewees got stuck along the line and could not answer some
questions in English but Finnish rather. Translation from Finnish to English needed to be done
23
while re-listening to the audio tape over and over. Everything said by the interviewees were
transcribed by the interviewers. The files were named “Interview unit 6” “Interview unit 7”
and after the thesis was written, the recordings were erased.
7.3 Data analysis
Content analysis can be used either in an inductive or deductive way, inductive method was
used in this thesis. Firstly, the data collected from the interviews were transcribed by listen-
ing to the tape recorder many times in a word document. The word documents were printed
out to make it more manageable to find out the main findings relating to the research ques-
tion. Many similarities were found which were grouped by highlighting in different color keep-
ing the research questions in mind. In the meantime, simplifications of the long text were
also made. Two examples of simplifying raw data are shown in the Figure 3. For example, all
simplifications that expressed about educating patients were highlighted with green and
wound care with yellow. Grouping was done by writing down in paper following the same
color or data talking about the same topic.
Figure 3: Example of simplifying raw data The strategy was to develop a sub-category when the writer finds two or more similar simpli-
fications and avoid unnecessary things that didn’t correspond to the research question. The
formation of categories was all written down in paper making it easy to observe all simplifica-
tion altogether and to check it by moving forward and backward. Progression in development
of categories is established when moving categories back and forth (Mariette Bengtsson,
2016). Example of forming sub-category is shown in Figure 4.
--when patient is discharged from the
hospital, we give them instructions about how to pro-ceed if the wound
gets infected
Guidance is given to patients while being
discharge
Abdominal part of body, around it has
bacteria which increas-es the chance of infec-
tion
Sometimes body itself
is a carrier
24
Figure 4: Example of forming sub-categories Altogether eighteen subcategories were developed and after this, the best option was only to
develop generic category in order to make it less complicated for proceeding the next step of
developing main categories and to receive relevant main categories. Example of forming ge-
neric category is shown in figure 5. Depending upon the relationship between sub-categories,
eight generic categories were formed by combining seventeen sub categories and one of the
simplifications was left it out to sub category only as it couldn’t be included to higher catego-
ry.
Figure 5: Example of forming a generic category At the end, the four main categories were formed. Example of forming main category is given
in the figure 6. While developing main categories, writers made sure that the research ques-
tion are being answered through it. The writers need to discuss and view their opinions re-
garding the categorization (Satu Elo and Maria Kääriäinen, 2014). It took several hours for
both writers to agree on all categories. Formation of all categories are shown in Figure 8.
Guidance is given to pa-tients while being dis-
charge Guidance are given for follow up care
Guidance given about not using alcohols is given be-
forehand
Basic aseptic tech-niques are taught to
patients
we advise to avoid unnecessary touching
to wound
Guidance given dur-ing the hospital stay
25
Figure 6: Example of forming main category
Translation to English was done in the first phase already in order to have better understand-
ing as it was difficult to do so in Finnish language. Translation of Finnish to English was made
using internet and writer’s own knowledge, and no other individuals were involved. The ex-
ample for the translation of quotation is shown in figure 7. In the similar way other data were
also translated.
Figure 7: Example of Translation from Finnish to English
‘‘perehdys alussa annettu ohjeet haa-
vasta’’
Information about the wound is given during the orienta-
tion period
Instructions given after discharge
instructions given during the hospital
stay
Educating patients
26
Figure 8: All categories
SUB-CATEGORY GENERIC CATEGORY MAIN CATERORY
THE WOUNDS NEED TO BE DRY.
THE WOUND IS CHECKED ON DAILY
BASIS THREE TIMES A DAY.
WE USE WOUND BANDAGE ONLY WHEN IT’S SECRETING.
DRY WOUND HEALING
OBSERVANT DAILY WOUND CARE
AFTER 24 HOURS, WOUND BANDAGE IS OPENED
WOUND DRESS-ING
RISK OF INFECTION ARE HIGHER WITH OBESE AND DIABETES PATIENTS
DEMENTED PATIENT TOUCHES
WOUND WITHOUT ACKNOWLEDING IT
A GOOD BALANCE DIET IS ALWAYS NEEDED
MEDICAL HIS-TORY
CONSIDERING RISKS
WE ALSO DO NUTRITIONAL ANALYSIS
TEST
LACK OF NUTRI-ENTS
WE GIVE THEM INSTRUCTIONS FOR
FOLLOW UP CARE
WE PROVIDE THEM GUIDANCE FORMS WHEN THEY LEAVE FOR HOME
BASIC ASEPTIC TECHNIQUES ARE TAUGHT TO PATIENTS
INSTRUCTIONS GIVEN AFTER DISCHARGE
EDUCATING PA-TIENTS
WE ADVICE TO AVOID UNNECESSARY TOUCHING TO WOUND
INSTRUCTIONS GIVEN DURING THE HOSPITAL
STAY
FIRSTLY, BLOOD SAMPLE ARE EXAM-INED
ANTIBIOTIC TREATMENT IS STARTED
MEDICAL TREAT-MENT
FOLLOW-UP OF THE PROCEDURES
AFTER WOUND CARE
WE ADVICE PATIENT TO WALK AS MUCH AS POSSIBLE
SOME PATIENT END UP BEING BED RIDDEN DUE TO PAIN
MOBILITY
LACK OF MOBIITY ALSO AFFECTS
WOUND HEALING
WE DONT HAVE ANY WOUND CARE TEAM
27
8 Findings
The thesis’s purpose was to describe “What do nurses do to prevent infections in surgical
patients with abdominal wounds?”. The data was collected by interviewing four registered
nurses in two different wards. Interviews were analyzed using inductive content analysis.
Based on the analysis, four main categories were produced using inductive content analysis:
wound care in post-operative phase, risks taken in considerations, educating patients and
procedure followed after wound infection.
8.1 Observant daily wound care
This main category was formed by joining two generic categories, ‘‘dry wound healing’’ and
‘‘wound dressing’’ and four sub-categories which are illustrated in Figure 8. The ward didn’t
have a team that specifically take care of wound, but nurses and ward doctors are responsible
for patient’s wound care. Wounds are assessed by nurses every day and sometimes doctors as
well if needed. Antibiotics are important to treat postoperative infected wounds and it is
done under the prescription of doctors. Wounds are assessed regularly, evaluated and docu-
mented by nurses based on the healing process. Holistic assessment of the patient is an im-
portant part of the wound care process as well as keeping a healthy diet. Proper wound dress-
ing always comes first during wound care. Use of sterile medical tape, gloves and bandages.
Wounds are covered with a bandage or gauze dressing and should be changed daily if needed.
Nurses ensure that all workers follow all the hygiene techniques when taking care of infected
wounds. Enhancing patient outcomes and promoting fast wound healing is one of nurses’ par-
amount goal. In addition, keeping the wound clean and dry is also one major factor nurses put
into consideration when taking care of infected wounds. Clean environment helps in preven-
tion of infection and since patient’s environment is a major reservoir of microorganisms,
cleaning personnel are trained about the right chemicals to use when cleaning patient´s
room. Nurses also explained that patients themselves are always involved in every plan they
figure out for the further care.
“Ei koskaan koske haava.’’
‘’Never touch your wound without any protection.’’
8.2 Considering risks
Two generic categories ‘‘medical history’’ and ‘‘lack of nutrients’’ developed second main
category which was followed by four sub-categories. The names of the sub-categories are
represented in Figure 8.
28
Preoperative patients and postoperative patients are being taken care of in the same ward by
the same nurses, and if proper hand hygiene is not followed strictly by the nurses and the
patients, it becomes so easy for a postoperative patient to get an infection from preoperative
patient and vice versa. If the nurses don’t follow the correct aseptic, a patient awaiting sur-
gery might also get infected during the waiting time.
Further, nurses explained that factors such as: poor tissue healing from malnutrition such as
anorexic patients, poor medical history, obesity, smoking, alcoholic, dementia patients, and
lack of mobility, premature removal of wound closure or stress on the unhealed incision like
coughing are taken in consideration in wound care.
Malnutrition (anorexia) is very well known in younger patients and sometimes in adults as
well. Malnourished patients take time to heal due to weak immune system. There are occa-
sions younger refuse to eat the meal offered to them during their stay in the hospital be-
cause, they fear to gain weight. And as a result of this, most end up being at risk of infection.
Therefore, nurses are always making sure that patients are getting enough nutrients.
“Dementia patients with bad hygiene keep touching the wound because they end up forget-
ting that wound should not be touched when hands are not clean and some patients end up
taking off the bandage before the 24hrs time...”
8.3 Educating Patients
Third main category was developed by combining two generic categories ‘‘instructions given
after discharge’’ and ‘‘instructions given during the hospital stay’’ and four other sub-
categories. These sub-categories are shown in Figure 8.
Patients are educated on the prior or on the day of discharge about wound care. There cases
some patient would rather want to be discharged before time. The education is mostly about
hygiene and mobility. Anything unsterile that goes into the wound can cause infection espe-
cially if the wound has not been healed to a certain process. Sometimes patients do not un-
derstand the importance of mobility, so they end up becoming bed radiant with the excuse of
pain. Patients who are clients of home care service are provided with clear written instruc-
tions about the wound that need to be followed by the nurses when they go to various home
to provide care. There are occasions whereby home care nurses call the hospital if the writ-
ten instructions are not clear or when the wound does not seem to heal.
“Patients are educated about wound care because most of them think the wound is healed
and everything is fine that is why they are being discharged”.
“The patient must be walking as much as possible.’’
29
It is the responsibilities of the nurses to educate significant others about how wound should
not be contaminated in cases whereby the surgical patient has dementia, Alzheimer, alcohol-
ic, etc. or when a patient will intentionally will not want to follow the instructions given to
be take home. This happen quite often with older patients who think they have lived more
enough.
“When discharging a patient, it’s very important to give them verbal and written infor-
mation”
8.4 Follow-up of the procedures after wound care
Last main category was developed firstly by combining five sub-categories to form two gener-
ic categories ‘‘medical treatment’’ and ‘‘mobility’’. The process of categorization is shown in
figure 8.
The procedure followed in the ward after the wound is infected starts with the bacteria tests
prescribed by a doctor. Based on the type of bacteria, doctors start antibiotic treatment, and
it also depends upon type of wound that patient has. Wound is checked constantly by the
doctors and nurses daily.
Cleaning of the wound and basic hygiene is strictly needed to be followed to prevent further
complication. Nurses had many cases where the infection of the wound made patients to stay
longer at hospital. The nurses also mentioned about the most common equipment used in the
ward for the infected wound known as vacuum-assisted closure (VAC). A VAC machine is used
to drain secreted wound after it has been infected. The VAC machine is similar to suction
machine and helps remove pressure over the area of the wound.
The machine helps wound heal more quickly by draining excess fluid from the wound, reduces
swelling and bacteria in the wound, keeps wound moist and warm, helps draw together
wound edges, increases blood flow to the wound and decreases redness and inflammation.
Some other factors mentioned in the interview were mobility and nutrients. Nurse explained
the importance of mobility for faster healing process of wound infection. For example, walk-
ing as much as possible and not just lying in a bed. Good balance diet is always important
after surgery. Especially with malnourished patients and patients lost a lot of blood during
the course of the surgery. The nurses recommended the use of supplements since patients
need energy after surgery, during the wound healing process and also due to blood loss in the
intraoperative phase. Patients’ BMI are checked on regular basis. When a patient is dis-
charged a form is given to be fill in incase the wound gets infected at home.
“Monesti infektiot ilmeinen vasta potilas lähtee kotiin, kun hoidetaan meille lyhyt sitten, me
annettaan ohjeet miten hän voi ette seurata siitä haava, jos alkaa tulehdus.’’
30
“Often patient gets infection after getting discharged, we give them instruction for the fol-
low up care.’’
“Patients are given Nutridrink 2-3 times a day after doctors’ prescription”.
“After 24 hours, bandage should be removed to check the wound if there is any secretion”.
9 Discussion
9.1 Discussion of the findings
The purpose of the thesis was to describe what nurses do to prevent infections in surgical
patients with abdominal wounds. The research question of the thesis was “What do nurses do
to prevent infections in surgical patients with abdominal wounds?” Four female nurses shared
their experiences regarding the abdominal wound care. The recordings received from the
interview was played many times, using the inductive content analysis and it was categorized
into four topics. Thus, the purpose of the thesis and the research question was established.
Talking of the interview, the four nurses had almost the same experiences and knowledge
about abdominal wound care even though two of them have not been working in the nursing
field for long compared to the other two nurses. The process the nurses follow to prevent
infection during postoperative care is also connected to the pre-operative phase. During the
course of the interview, the nurses were more prepared, and all the questions were asked in
a professional way. Because of their busy schedules, the writers decided not to put any pres-
sure on them but rather, waited for them to give us a convenient date, time and place of
their own whenever they are ready to be interviewed. The nurses seemed really prepared as
all answers were answered professionally. All the answers given really showed that their
knowledge about abdominal wound infection is deep due to their experiences.
Also, the nurses pointed out that during hospital stay and before discharge, they educate
patients and significant others about wound care especially on how not to contaminate the
wound. This signifies that, patients’ wellbeing and safety is of importance to them. It also
tells the empathy they have for their patients. The prevention procedures that the writers
found out are very simple and easy to be followed in all the healthcare centres and in homes
as well. Majority of surgical site infections is preventable if the right procedures being taught
are followed accordingly. One of the nurses showed the writers of the thesis how PICO ma-
chine works because she talked about it during the interview. Luckily, there was a patient
using the machine. Before the PICO machine was showed to the writers, the nurse had to ask
permission from the patient whose wound has been infected and needed to be treated by the
machine. The patient gave the permission and was not bothered while the nurse was showing
the writers how the machine drains the secreted wound. After everything was done, the writ-
ers thanked the patient for collaborating.
31
There were some challenges the writers faced during the writing of the thesis. Firstly, a
permission letter needed to be sent to the hospital for approval before the writers could pro-
ceed with the thesis. A reply was received after a month by the clinical teacher at the hospi-
tal that, the letter and the questionnaires should also be in Finnish language and not only in
English. It took the writers more than a week before the letter was translated from English to
Finnish since both writers of the thesis are international students. After the letter and other
forms that needed to be fill and signed by the writers was emailed to the clinical teacher
before the hospital approves, it took some time before the clinical teacher replied and that
was when a reminder email had been sent to her. The writers of the thesis were told even
though everything has been approved, registered volunteer nurses to participate in the inter-
view are lacking due to their busy schedules.
The clinical teacher later asked the writers if they have other options to complete their thesis
in case no one volunteers to participate. The reply was there is no other option, so she should
try her best and get the writers a minimum of four nurses. Finally, one registered nurse vol-
unteered and after some weeks, three more nurses volunteered as well and that was how the
writers got four nurses to participate in their final project. Another major challenge was tran-
scribing the Finnish part of the data as mentioned earlier on both writers are international
students. In all it took about four months before everything was done starting from getting a
permission from the hospital to interviewing the four registered nurses. The clinical teacher
asked a copy of thesis once it is completed.
The findings of this study showed that, infection can be prevented when all the aseptic tech-
niques are followed accordingly by the health care workers and patients. The researchers
have gained more insight about surgical site infections and at the same time, the preventive
measures that need to be taken to prevent infection starting from preoperative phase to the
postoperative phase. In our opinion, the prevention methods are very wide and simple to
follow if they are put into practice. In addition, some of the references in this thesis are very
old and the care practices may have changed. Therefore, the trustworthiness is not very
tight.
9.2 Ethical considerations of the thesis
According to Ezzy (2002, p72), ethics in research is an essential matter which must be put
into consideration in order to protect the rights of the participants. Beginning from the in-
formed consent, confidentiality and guaranteed anonymity, voluntary participation with the
right to withdraw at any time, the role of the researcher, not twisting data and loyalty.
Smeltzer and Bare (1992, p50), defines ethics as the philosophical study of morality, and one
relies on formal theory rules, principles, or codes of conduct to determine the “right” course
of action. Transparency plays a vital role as well as communicability in ethical consideration.
32
In other words, researchers must be able to communicate in clear manner that readers get a
clear understanding without any misinterpretation of the study (Auerbach & Silverstein 2003,
50).
A cover letter was attached to the thesis plan, direct to the clinical teacher to gain her con-
sent from the participants (Appendix 4). And approval to conduct the research was given from
the head nurse of the department. A second letter was also sent to the participants also
known as the volunteer interviewees informing them about the thesis, with the assurance of
not revealing their identity to a third party (Appendix 5 and 6). Furthermore, questionnaire
was given on the day of the interview. The language of the interview was English but was also
be answered in Finnish language as well. The clinical teacher gave us the permission to con-
duct the interview and also emailed us all the necessary forms that needed to be filled and
signed.
Conducting research requires, confidentiality, honesty, integrity and diligence. All the par-
ticipants of the thesis were kept anonymous and the data collected was kept confidential.
The writers’ practiced right to autonomy and confidentiality after obtaining the signed con-
sent form of the participants. The whole thesis process followed Laurea guidelines that are
set by Laurea University of Applied Sciences. The thesis topic was approved during the thesis
meeting together with other students and later, the topic analysis was also approved by our
supervising and tutor lecturer. Ethical considerations were built from the topic of the thesis
to the publication of the thesis (Burns and Groove 2001, 191).
9.3 Trustworthiness of the thesis
Polit & Beck (2010. p 492), has described the four-category credibility, dependability, con-
firmability and transferability suggested by Lincoln and Guba (1985) for developing the trust-
worthiness of a qualitative study. Credibility is defined as the truthiness of the data that are
interpreted; dependability refers the reliability of data over any other conditions; confirma-
bility interprets focusing on the interviewees’ thoughts and experiences rather than own
views; lastly transferability refers to produce findings in a way so that other researchers can
interpret for similar settings (Polit & Beck, 2012 p492). All these four categories were as-
sessed during the whole process of writing a thesis.
The authors explained only the data provided by the participants of the interviews, reflecting
their views and opinions in details, avoiding bias while interviewing. Trustworthiness has been
put in all areas starting from the choosing the topic and research questions to research meth-
od to planning, to the implementation, to the evaluation and the publication by a mutual
understanding and communication between both the authors and the tutors. While choosing
the research method, options were created in which qualitative method was the best way to
33
achieve finding for the chosen research question. The participants were informed before-
hand, but the interviews questions were shown to them on the day of the interview.
The guidance of the tutors was also highly taken in consideration in the process of writing the
thesis. The writers have provided sufficient information about the whole thesis; describing
the study in a well detailed way for readers to be able evaluate it. This thesis has evaluated
the trustworthiness by using the methods mentioned above; by also evaluating each aspect of
the thesis and looking at its trustworthiness (Elo & Kyngäs., 2007)
Trustworthiness is an important fundamental principle to qualitative research. It is showed by
the findings portraying the reality of the experience. As said by Auerbach and Silverstein
(2003, 60), trustworthiness should be able to relate to the purpose and case to the study.
When assessing trustworthiness, the purpose and length of the study, the researcher’s com-
mitment and relation-ship between the informant, data collection, data analysis, reliability
and lastly reporting the analysis should all be evaluated (Auerbach & Silverstein, 2003, 58).
In all, the trustworthiness of this study has been put into consideration throughout the whole
study. Because surgical site infection is a very wide topic and can be discussed from different
angles. The purpose of the study is to describe how nurses prevent abdominal wound infec-
tions.
9.4 Conclusions and recommendations
In conclusion, the results of the research show that surgical site infection can be prevented if
all the aseptic techniques are follow correctly starting from the preoperative phase to the
postoperative phase. Nurses, surgeons, ward doctors and cleaning personnel have pivotal role
to prevent infection as they deal with surgical patients. A clean environment is always the
first step to begin with when dealing with wounds. Also, nurses play a major role by educating
patients about good hygiene before, during and after surgery. Surgical site infection is a very
broad topic and can be discussed from different angles.
Based on the findings of the thesis, following recommendations are made. First the hospital
didn’t have infection control team but rather surgeons, ward doctors, nurses, students and
sometimes patients themselves prevent infection which is a good idea but if a team of nurses
are specifically trained about abdominal wound infection, it would be easier for the nurse
who has been trained to detect when a wound is about to be infected. Also, this would make
nurses work easier since a nurse who has not had special training about abdominal wound
would only take of clean wounds whilst the nurse who has extra training wound infection will
take care of infected wounds. This procedure will also help in the prevention of infection.
Secondly, simple and readable posters talking about infection prevention should at the hospi-
tal surroundings so that incoming and outgoing visitors can read and enlighten themselves
34
about infection. Surgical site infection has become one of the most leading cause of hospital-
ized postoperative patients, financial loss to families and the country as a whole. Basic
knowledge of aseptic techniques and its applications can help decrease infection.
Also, patients with infected wounds should be isolated from patients with clean wounds. This
method can prevent the spread of infections among patients since the ward does not consists
of postoperative patients only but preoperative patients as well. Since the interview was con-
ducted in patients’ living room and door had to be locked to prevent a patient from entering
during the interview. The writers of the thesis will recommend if the hospital gets a separate
spare room where doctors, nurses and significant others can meet and discussion about pa-
tient’s continuous care.
35
References
Abdominal Surgery, No date. Accessed 15th of Jan, 2018.
https://www.floridahospital.com/abdominal-surgery
Annette B. Wysocki Surgical Wound Healing published 1989. Accessed 27th March 2018 https://aornjournal.onlinelibrary.wiley.com/doi/pdf/10.1016/S0001-2092%2807%2966673-3
Antall GF, Kresevic D. The use of guided imagery to manage pain in an elderly orthopaedic population, 2004. Accessed 7th Feb, 2018. https://www.ncbi.nlm.nih.gov/pubmed/15554471
Arain Shahbaz R., Ruehlow Renée M., Uhrich Toni D., Ebert, Thomas J. The Efficacy of Dex-medetomidine Versus Morphine for Postoperative Analgesia after Major Inpatient Surgery pub-lished Jan 2004. Accessed 15th April 2018. https://journals.lww.com/anesthesia-analgesia/Fulltext/2004/01000/The_Efficacy_of_Dexmedetomidine_Versus_Morphine.41.aspx
Bansal C1, Scott R, Stewart D, Cockerell CJ., Decubitus ulcers: a review of the literature, 2005. Accessed 8th Feb, 2018. https://www.ncbi.nlm.nih.gov/pubmed/16207179 Blaxter, L., Hughes, C. & Tight, M. How to Research. Buckingham: Open University Press. Published 1999. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma A, Carr K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Published Feb 2005. Accessed 26th March 2018 https://academic.oup.com/cid/article/38/12/1706/304336 Burke John P. Infection Control — A Problem for Patient Safety, New England Journal of Medi-cine, vol. 348, no. 7, pp.651–656 Published 2003. Accessed 26th March 2018 http://www.ccmpitt.com/ebm/infectious_disease/215-%20NNIS%20INfection%20Control.pdf Burns, N. & Groove, K. 2001 4th Edition, The Practice of Nursing Research, Conduct, Critique & Utilization, W.B Saunders Company, 365 Carl F. Auerbach and Louise B. Silverstein Accessed 26th Feb, 2018. https://epdf.tips/qualitative-data-an-introduction-to-coding-and-analysis.html
Carey P. Page, John M. A. Bohnen, J. Raymond Fletcher, Albert T. McManus, Joseph S. Sol-omkin, Dietmar H. Wittmann. Antimicrobial Prophylaxis for Surgical Wounds Guidelines for Clinical Care, Published Jan 1993. Accessed 28th April 2018. https://jamanetwork.com/journals/jamasurgery/article-abstract/595585?redirect=true
Chang CC, Lin HC, Lin HW, Lin HC. Anaesthetic management and surgical site infections in total hip or knee replacement: a population-based study. Published Aug 2010. Accessed 27th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/20657202/
Daniel J Quemby, Mary E Stocker Day surgery development and practice: key factors for a successful pathway published 05 Dec 2013. Accessed 8th April 2018. https://academic.oup.com/bjaed/article/14/6/256/247587
Daisy Jane Antipuesto Rn Mn, April 27, 2011, Intraoperative Phase, Accessed 17th Feb, 2018. http://nursingcrib.com/perioperative-nursing/intraoperative-phase/
Denise F. Polit and Cheryl Tatano Beck. 2012. Nursing research: Generating and assessing evi-dence for nursing practice. Ebook. 9th edition. USA: Philadelphia.
36
David Saltissi, Colleen Morgan, Justin Westhuyzen, Helen Healy Comparison of low-molecular-weight heparin (enoxaparin sodium) and standard unfractionated heparin for haemodialysis anticoagulation, published Nov 1999. Accessed 15th April 2018. https://academic.oup.com/ndt/article/14/11/2698/1807905 Elo S1 & Kyngäs H, The qualitative content analysis process, April, 2008, Accessed 1st of June, 2018. https://www.ncbi.nlm.nih.gov/pubmed/18352969 Ezzy, Douglas. Qualitative Analysis: Practice and Innovation. London: Routledge. Published 2002.
European Centre for Disease Prevention and Control. Annual Epidemiological Report 2016 – Surgical site infections, 2016. Accessed 17th feb, 2018. https://ecdc.europa.eu/sites/portal/files/documents/AER-HCAI_SSI.pdf
Flick, U. An Introduction to Qualitative Research. London: Sage. Published1998.
Frankfort-Nachmias, C. & Nachmias, D. Research Methods in the Social Sciences, 5th ed. New York, NY: St. Martin’s Press. Published 1996. Gottrup F, Oxygen in wound healing and infection, 2004. Accessed 8th feb, 2018. https://www.ncbi.nlm.nih.gov/pubmed/14961190
Greta L. Piper, Lewis J. Kaplan Critical Care of the Abdominal Surgery Patient; Intra-peritoneal Surgery; Emergency General Surgery; Elective General Surgery, published20th Dec 2016 .Accessed 15th Jan 2018 https://www.cancertherapyadvisor.com/critical-care-medicine/critical-care-of-the-abdominal-surgery-patient-intra-peritoneal-surgery-emergency-general-surgery-elective-general-surgery/article/586032/
Halpin LS, Speir AM, CapoBianco P, Barnett SD, Guided imagery in cardiac surgery, 2002. Ac-cessed 7th Feb, 2018. https://www.ncbi.nlm.nih.gov/pubmed/12134377
Hemant Singhal, MD, MBBS, MBA, FRCS(Edin), FRCS, FRCSC Wound Infection Clinical Presenta-tion, May 05, 2017. Accessed 14th Jan, 2018. https://emedicine.medscape.com/article/188988-clinical Indian journal of plastic surgery No date. Accessed 30th Sep 2018. http://www.ijps.org/viewimage.asp?img=ijps_2012_45_2_291_101301_f1.jpg Jean-Pierre A. Riou, Jon R. Cohen, Houston Johnson Jr. Factors influencing wound dehiscence Published March 1992. Accessed 28th April 2018. http://www.americanjournalofsurgery.com/article/0002-9610(92)90014-I/fulltext
Jennifer Whitlock, Perioperative Care in Surgery; What to Expect Before, During, and After Surgery, updated 2018. Accessed 3rd of Feb, 2018. https://www.verywell.com/perioperative-defined-3157137 Joanna Chrzanowska, Interviewing Groups and Individuals in Qualitative Market Research, 2002. Accessed 5th Sept, 2018. https://books.google.co.uk/books?id=uF0DT4jhMNQC&printsec=frontcover&hl=fi&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false Johns Hopkins Surgical site infections Accessed 5th Jan, 2018. https://www.hopkinsmedicine.org/healthlibrary/conditions/surgical_care/surgical_site_infections_134,144 Johnson A, Young D, Reilly J. Caesarean section surgical site infection surveillance. Published 5th July 2006. Accessed 27th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/16822582/
37
Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site in-fections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.Published Nov 1999 Accessed 26th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/10580621
KCI Acelity company,2013. Accessed 30th Sep 2018. https://www.kci-medical.ca/CA-ENG/products Leslie M. Plauntz Preoperative Assessment of the Surgical Patient published Sep 2007. Ac-cessed 15th April 2018. http://www.nursing.theclinics.com/article/S0029-6465(07)00028-X/fulltext
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Published April 1999. Accessed 26th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/10219875?report=docsum Marcia G.Tonnesen, Xiaodong Feng, Richard A.F.Clark Angiogenesis in Wound Healing pub-lished 1st Dec 2000. Accessed 15th April 2018. https://www.sciencedirect.com/science/article/pii/S0022202X15528571 Maria Schubert Tracy R. Glass Sean P. Clarke Linda H. Aiken Bianca Schaffert-Witvliet Douglas M. Sloane Sabina De Gees Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. Published 24th April 2008. Accessed 28th April 2018. https://academic.oup.com/intqhc/article/20/4/227/1846768 Mariette Bengtsson, How to plan and perform a qualitative study using content analysis, 2016. Accessed 15th Nov, 2018. https://www.sciencedirect.com/science/article/pii/S2352900816000029#bib501
Marshall, C. & Rossman, G.B. (1999). Designing Qualitative Research. Thousand Islands, CA: Sage Publications.
MaryAnn DePietro, Surgical Wound, 2014. Accessed 29th of Jan, 2018. https://www.healthline.com/health/surgical-wound#types Mary Patricia O'Connell Positioning Impact on the Surgical Patient published June 2006, Ac-cessed 8th April 2018. http://www.nursing.theclinics.com/article/S0029-6465(06)00011-9/fulltext
National Institute for Health and Care Excellence, Surgical site infections: prevention and treatment, 2008. Accessed 3rd Feb, 2018. https://www.nice.org.uk/guidance/cg74/chapter/1-guidance Nichols, R. 2001 Preventing surgical Site Infections: A Surgeons Perspective, Accessed 16th feb 2018. http://www.cdc.gov/ncidod/eid/vol7no2/nichols.htm
Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. Published Nov 2008. Accessed 27th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/19022115
Paul K. Mohabir & Jennifer Gurney Introduction to Care of the Surgical Patient published May 2015, Accessed 8th April 2018. https://www.merckmanuals.com/professional/special-subjects/care-of-the-surgical-patient/introduction-to-care-of-the-surgical-patient
Pomposelli JJ, Baxter JK 3rd, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, Bistrian BR. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients, Published 1998 Mar-Apr. Accessed 27th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/9527963/
38
Robert W. Haley; David H. Culver; John W. White; W. Meade Morgan; T. Grace Emori The Nationwide Nosocomial Infection Rate: A New Need For Vital Statistics, published 1st Feb-ruary 1985. Accessed 17th April 2018. https://academic.oup.com/aje/article-abstract/121/2/168/113798?redirectedFrom=fulltext
Ronald Lee Nichols Postoperative infections in the age of drug-resistant gram-positive bacte-ria published 29th May 1998. Accessed 17th April 2018. http://www.amjmed.com/article/S0002-9343(98)00150-8/fulltext Satu Elo , Maria Kääriäinen , Outi Kanste, Tarja Pölkki , Kati Utriainen, and Helvi Kyngäs, 2014, Qualitative Content Analysis: A Focus on Trustworthiness. Accessed 5th Nov, 2018 http://journals.sagepub.com/doi/pdf/10.1177/2158244014522633
Sessler DI. Non-pharmacologic prevention of surgical wound infection, published Jun 2006. Accessed 27th March 2018. https://www.ncbi.nlm.nih.gov/pubmed/16927930/
S.M. McHugh, M.A. Corrigan, A.D.K. Hill, H. Humphreys Surgical attire, practices and their perception in the prevention of surgical site infection. Accessed 28th April 2018. http://www.thesurgeon.net/article/S1479-666X(13)00126-1/fulltext Sapsford, R., & Abbott, P., 1992, Research Methods for Nurses and the Caring Professions, Open University Press USA 98,108 Satu Elo, Maria Kääriäinen, Outi Kanste, Tarja Pölkki, Kati Utriainen, and Helvi Kyngäs. Quali-tative Content Analysis: A Focus on Trustworthiness, Published February 11, 2014. Accessed 22nd Feb,2018. http://journals.sagepub.com/doi/pdf/10.1177/2158244014522633
Seltzer, J., McGrow, K., Horsman, A., Korniewicz, D., 2002 Awareness of Surgical Site Infec-tions for Advanced Practice Nurses. Accessed 16th Feb 2018. https://www.ncbi.nlm.nih.gov/pubmed/12151993 Shruti Datt, 8-step procedure to conduct qualitative content analysis in a research, October 16, 2016, Accessed 1st of June, 2018. https://www.projectguru.in/publications/qualitative-content-analysis-research/
Smeltzer, S., & Bare, B.,1992, Medical Surgical Nursing. 7th Edition J. B. Lippincott Company 50,421
S. Guo, L.A. Di Pietro, 2010. Factors Affecting Wound Healing. Accessed 16th Feb, 2018. http://journals.sagepub.com/doi/abs/10.1177/0022034509359125
Strik C, Stommel MW, Schipper LJ, van Goor H, Ten Broek RP. Risk factors for future repeat abdominal surgery, published April 2016. Accessed 10th Jan 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5009167/
Surgery: Overview, 2012, Accessed 15th Jan, 2018. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0027957/
Surgery. Accessed 15th Feb, 2018.https://www.clinicaladvisor.com/critical-care-medicine/critical-care-of-the-abdominal-surgery-patient-intra-peritoneal-surgery-emergency-general-surgery-elective-general-surgery/article/586031/
Surgical wound. Accessed 8th Jan, 2018. https://www.woundcarecenters.org/article/wound-types/surgical-wounds
Schuster KM, Davis KA, Rosenbaum SH. Emergency and urgent surgery published Sep 2009. Accessed 15th April 2018. https://www.ncbi.nlm.nih.gov/pubmed/19665625
39
Svend Brinkmann Qualitative Interviewing. Accessed 2nd March,2018. https://global.oup.com/academic/product/qualitative-interviewing-9780199861392?cc=fi&lang=en&#
Theodoros E. Pavlidis, Ioannis N. Galatianos, Basilios T. Papaziogas, Charalabos N. Lazaridis, Konstantinos S. Atmatzidis, John G. Makris, Thomas B. Papaziogas, Complete Dehiscence of the Abdominal Wound and Incriminating Factors. Published 4th Dec 2011. Accessed 28th April 2018. https://www.tandfonline.com/doi/pdf/10.3109/110241501750215221?needAccess=true
Thomas Bodenheimer, Kate Lorig, Halsted Holman; et al Patient Self-management of Chronic Disease in Primary Care published Nov 2002, Accessed 8th April 2018. https://jamanetwork.com/journals/jama/article-abstract/195525?redirect=true
Vikram Kate, Exploratory Laparotomy, Updated 2018. Accessed 15th of Jan, 2018. https://emedicine.medscape.com/article/1829835-overview
Voda Sandra C Same-day surgery nursing: It takes teamwork published Jan 2011, Accessed 8th April 2018. https://journals.lww.com/nursing/Fulltext/2011/01001/Same_day_surgery_nursing__It_takes_teamwork.8.aspx
Walker J Emotional and psychological preoperative preparation in adults, published 25th May 2002. Accessed 15th April 2018. https://www.ncbi.nlm.nih.gov/pubmed/11979210
Walker J Philosophy, knowledge and theory in the assessment of pain, published 24th May 2003. Accessed 15th April 2018. https://www.ncbi.nlm.nih.gov/pubmed/12743479 Young PY, Khadaroo RG, 2014, Surgical site infections. Accessed 17th Feb, 2018. https://www.ncbi.nlm.nih.gov/pubmed/25440122
40
Table
Table 1: Types of surgical site infection……………………………………………………………………16
41
Figures
Figure 1: Cross-section of abdominal wall depicting CDC classifications of surgical site
Infection...............................................................................15
Figure 2: Data collection process................................................................21
Figure 3: Example of simplifying raw data.....................................................23
Figure 4: Example of forming sub-categories..................................................24
Figure 5: Example of forming generic category................................................24
Figure 6: Example of forming main category...................................................25
Figure 7: Example of Translation from Finnish to English.....................................25
Figure 8: All categories.............................................................................26
42
Appendices
Appendix: 1 Factors Influencing Surgical Infections............................................43 Appendix: 2 Chain of Infection....................................................................44 Appendix: 3 Consent form for Participation in Interview......................................45 Appendix: 4 Cover letter for the ward manager.................................................46 Appendix: 5 Cover letter for the participating nurses/interviewees.........................47 Appendix 6: Cover letter for the participating nurses/interviewees in Finnish.............48
43
Appendix: 1 Factors Influencing Surgical Infections
According to Nichols (1998) perioperative infection are caused by many factors such as the
length and type of surgery, the surgical team, history of the patient etc.
PATIENT VARIABLES PRE-OPERATIVE
PHASE
INTRA-OPERATIVE
PHASE
POST-OPERATIVE
PHASE
Chronic disease Prophylatic
antibiotic
Type of surgery Hand washing
Age Surgery Surgical technique Asepsis principles
Immunosuppressive
drugs
Skin preparation
clipping/showering
Skin-closure
techniques
Proper wound man-
agement(dressing)
General physical
condition
Patient length of
hosptilization (ward)
Duration of surgery Mobility and pain
control
Skin condition Catheterization Extent of tissue loss Adequate wound
discharge
Nutritional Time intervals Environment
Infection Patient length of
hosptilization (ward)
Early discharge
Overweight
Hydration
44
Appendix: 2 Chain of Infection, Ziegler M. (2010)
SUSCEPTIBLE HOST Immunosuppres-sion Diabetes Surgery Burns Elderly
INFECTIOUS AGENTS
• Bacteria
• Fungi
• Viruses
RESEVOIRS
• People
• Equipment
• Water
PORTAL OF ENTRY
• Mucous membrane
• G I tract
• G U tract Respiratory
MEANS OF TRANS-MISSION
• Direct con-tact
• Ingestion
• Fomites
• Airborne
PORTAL OF EXIT
• Excretions
• Secretions
• Skin
• Droplets
45
Appendix: 3 Consent form for Participation in Interview
I, hereby, agree to participate in this individual interview. I understand that the interview is
part of bachelors’ thesis, “Infection prevention in surgical patients with abdominal wounds”
by Manisha Udash and Doris Appiagyei Agyare.
• I understand that I am participating in the thesis project for bachelor’s degree.
• I understand that no payment will be made for the participation.
• I understand that I can withdraw anytime if I do not want to continue with the inter-
view.
• I understand that I have right to decline answering any questions that I am not com-
fortable with.
• I understand that the interview can take up to 60 minutes.
• I understand that the interview will be recorded.
• I give permission to record my thoughts that I put during the interview.
• I understand that my name will not be mentioned in the thesis or any report made
based on this interview.
• I understand that this thesis project will be reviewed and approved officially.
• I have read and understood the explanation provided to me. I have had all my ques-
tions answered to my satisfaction, and I agree to participate in this study.
My Signature, ____________________________
Date ____________________________
Manisha Udash Doris Appiagyei Agyare Sari Haapa
Nursing Student Nursing Student Thesis Tutor, Senior Lecturer
Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi
Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi
46
Appendix: 4 Cover letter for the ward manager
Dear Ward Manager,
We are graduating nursing students in Degree programme in English from Laurea University of
Applied Sciences. As thesis is part of the requirement of our study programme, we have cho-
sen a topic ‘’Infection prevention in surgical patients with abdominal wounds’’ We chose this
topic because infection is one of the most pressing issues whenever a surgical operation is
involved. Infection end up causing overstay in the hospital, loss of money for the patient and
sometimes to the hospital as well due to long awaiting queue.
We kindly request for your permission to undertake our thesis in your ward and we will also
need your assistance in finding six English speaking registered nurses in the surgical ward,
who will assist with our questions. Interviews will be conducted in two or three groups or
individually if needed in a separately agreed place within their schedules. The interview will
take about 30 minutes.
The identity of the interviewees is only known to the writers of the thesis and will not be
revealed at the final presentation and publication of thesis. We commit to the obligation of
confidentiality and to adhere to good research ethics methods of writing the thesis. And un-
der no circumstances will there be a breach of contract.
Lastly, the theses of universities of applied sciences are published on Theseus.fi database and
if you wish, we can send you a link to our final thesis. We do hope that you grant us the per-
mission to carry out our thesis at your ward. Our contact is below in case you or the nurses
would like to reach us beforehand;
Doris (0469567482)
Manisha (0453113100)
Kind regards,
Manisha Udash Doris Appiagyei Agyare Sari Haapa
Nursing Student Nursing Student Thesis Tutor, Senior Lec-
turer
Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi
Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi
47
Appendix: 5 Cover letter for the participating nurses/interviewees
Dear Nurses,
We are graduating Nursing students in English programme at Laurea University of Applied
Sciences. Thesis is a part of our studies and our thesis topic is ‘’Infection prevention in surgi-
cal patients with abdominal wounds’’. Your personal experience of taking care of wounds and
preventing wound infection is of paramount importance. The results of the thesis may help to
improve wound care management.
The data will be collected by a semi structured interview. Interviews will be conducted in two
or three groups or individually if needed in a separately agreed place within their schedules.
The interview will take about 30 minutes. The interview language is English, but answers can
be can be given in Finnish language as well. If possible, we hope to conduct the interviews in
June or July. The interview will last about 30 minutes. We kindly ask you to participate in the
interviews related to the thesis.
Participation in the interview is voluntary and can be interrupted at any time. The interview
will be recorded, and the tape will be used only for the thesis. Interview material and the
recordings are kept so that only the authors of the thesis have the opportunity to see or listen
to them. The data will be erased after completing the thesis. The identity of the interviewees
is only known to the writers of the thesis and cannot be identified of the final thesis. We
commit to the obligation of confidentiality and to adhere to good research ethics methods of
writing the thesis.
The theses of the universities of applied sciences are published on Theseus.fi database and, if
you wish, we can send you a link to our final thesis. We hope that you will take part in the
interview. You can give your consent to the interview by signing the consent paper when we
meet. We have also given our contact to the ward manager and if you have any questions
about our bachelor's thesis, do not hesitate to contact us. We will be very delighted to answer
you before we meet in person. Getting the privilege to learn more from you will create
awareness for us and other nurses.
Kind Regards,
Manisha Udash Doris Appiagyei Agyare Sari Haapa
Nursing Student Nursing Student Thesis Tutor, Senior Lec-
turer
Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi
Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi
48
Appendix 6: Cover letter for the participating nurses/interviewees in Finnish
Hyvät hoitajat,
Olemme viimeistä vuotta opiskelevia sairaanhoitaja opiskelijoita englanninkieliseltä kurssilta
Laurea ammattikorkeasta. Oppinnäytetyö on osa opintojamme ja sen aiheena on "Tulehdusten
estäminen potilailla joilla on vatsan alueen leikkaushaava."
Teidän kokemuksenne leikkaushaavojen tulehduksien estossa on erittän tärkeä. Tämä
oppinnäytetyö toivottavasti tulee parantamaan haavojen hoitoa tulevaisuudessa.
Tiedot tullaan keräämään puolimuodollisella haastattelulla. Haastattelut tehdään
pienryhmissä aikataulujen niin salliessa, enintään 3 henkeä kerrallaan, haastattelu kestää
noin 30min. Haastattelu tehdään englanniksi mutta vastaukset voidaan antaa suomeksi myös.
Toivomme että haastattelut voidaan tehdä heinä- elokuussa. Pyydämme ystävällisesti, että
mahdollisimman moni osallistuisi haastatteluihin.
Osallistuminen haastatteluihin on vapaaehtoista ja voidaan keskeyttää milloin tahansa.
Haastattelut tallennetaan ja tallenteita tullaan käyttämään vain oppinnäytetyön tekemiseen.
Tallenteet poistetaan, kun oppinnäytetyö on valmis, haastateltavien henkilöllisyyttä ei tule
tietämään kukaan muu. Kaikki vastaajat anonymisoidaan oppinnäytetyössä. Me lupaamme
noudattaa luottamuksellisuutta ja hyvää tutkimus etiikkaa tehdessämme oppinnäytetyö.
Oppinnäytetyö tullaan julkaisemaan www.theseus.fi sivulla ja jos haluatte voimme lähettää
teille linkin valmiseen teokseen. Toivomme että osallistutte haastatteluun ja annatte
suostumuksenneallekirjoittamalla suostumuslomakkeen jonka annamme ennen haastattelua.
Olemme antaneet yhteystietomme osaston johtajalle, jos teillä on kysymyksiä
opinnäytetyöstämme älkää epäröikö kysyä. Vastaamme kysyksiinne ennen tapaamista. On ilo
päästä oppimaan lisää ja tuottaa lisää tietoisuutta kaikille hoitajille.
Ystävällisin terveisin,
Manisha Udash Doris Appiagyei Agyare Sari Haapa
Nursing Student Nursing Student Thesis Tutor, Senior Lec-
turer
Laurea UAS, Otaniemi Laurea UAS, Otaniemi Laurea UAS, Otaniemi
Manisha.Udash@student.laurea.fi Doris.a.agyare@student.laurea.fi Sari.Haapa@laurea.fi
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