Surgical wound assessment and documentation of nurses: an integrative review

Abstract

Objective: Surgical site infections (SSI) are serious complications that can lead to adverse patient outcomes such as prolonged hospital length of stay, increased health-care costs, and even death. There is an imperative worldwide to reduce the morbidity associated with SSIs. The importance of surgical wound assessment and documentation to reduce SSI complications is increasingly recognised. Evidence-based guidelines have been published internationally to highlight recommended practices. The aim of this integrated review is to evaluate current surgical wound assessment and documentation practices of nurses in order to inform future evidence-based research on acute wound care practices.

Method: Databases including CINAHL, Cochrane, Medline and Proquest Nursing were searched using key terms of ‘wound assessment’ AND ‘surgical, wound assessment’ AND ‘documentation, wound assessment’ AND ‘practice, wound assessment’ AND ‘postoperative, wound assessment’ AND ‘nurse, and wound assessment’ AND ‘surgical site infection’.

Results: A total of 188 articles were identified from the database searches; searching the reference lists provided an additional 8 articles. After careful exclusion processes, a total of six papers were included in the review. Despite the recommendations around wound assessment, there is little discussion on how the clinical characteristics of surgical wounds should be assessed, the frequency of the wound assessments and to what extent wound assessments are documented in the literature.

Conclusion: There is limited research evidence on acute wound assessment and documentation. Therefore, further research is needed to provide evidence for surgical nurses in relation to wound assessment and documentation practices.