A nurse is planning to perform wound irrigation for a client who has an open secondary wound

1. Barbul A. Wound care guidelines of the wound healing society: foreword. Wound Rep Regen 2006;14:645–646 [Google Scholar]

2. Eskes AM, Storm-Versloot MN, Vermeulen H, Ubbink DT. Do stakeholders in wound care prefer evidence-based wound care products? A survey in the Netherlands. Int Wound J 2012;9:624–632 [PMC free article] [PubMed] [Google Scholar]

3. Franz MG, Robson MC, Steed DL, Barbul A, Brem H, Cooper DM, et al.. Wound Healing Society. Guidelines to aid healing of acute wounds by decreasing impediments of healing. Wound Repair Regen 2008;16:723–748 [PubMed] [Google Scholar]

4. Gillespie BM, Chaboyer W, Kang E, Hewitt J, Nieuwenhoven P, Morley N. Postsurgery wound assessment and management practices: a chart audit. J Clin Nurs 2014. [Epub ahead of print]; DOI: 10.1111/jocn.12574 [PubMed] [CrossRef] [Google Scholar]

5. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al.. AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. J Clin Epidemiol 2010;63:1308–1311 [PubMed] [Google Scholar]

6. Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, et al.. GRADE Working Group. Rating quality of evidence and strength of recommendations: Going from evidence to recommendations. BMJ 2008;336:1049–1051 [PMC free article] [PubMed] [Google Scholar]

7. Brölmann FE, Vermeulen H, Go P, Ubbink D. Guideline ‘Wound Care’: recommendations for 5 challenging areas. Ned Tijdschr Geneeskd 2013;157:A6086. [PubMed] [Google Scholar]

8. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012; Issue 2, Art. No.: CD003861 [PubMed] [Google Scholar]

9. Gravett A, Sterner S, Clinton JE, Ruiz E. A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med 1987;16:167–171 [PubMed] [Google Scholar]

10. Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990;19:704–708 [PubMed] [Google Scholar]

11. Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for repair of dermal laceration. Cochrane Database Syst Rev 2011; Issue 6. Art. No.: CD005364 [PubMed] [Google Scholar]

12. Alessandri F, Lijoi D, Mistrangelo E, Nicoletti A, Crosa M, Ragni N. Topical diclofenac patch for postoperative wound pain in laparoscopic gynecologic surgery: A randomized study. J Minim Invasive Gynecol 2006;13:195–200 [PubMed] [Google Scholar]

13. Berben SA, Kemps HH, van Grunsven PM, Mintjes-de Groot JA, van Dongen RT, Schoonhoven L. Guideline ‘Pain management for trauma patients in the chain of emergency care’. Ned Tijdschr Geneeskd 2011;155:A3100. [PubMed] [Google Scholar]

14. World Health Organization. Cancer pain relief and palliative care 2012. WHO, Geneva, Switzerland. www.who.int/cancer/palliative/painladder/en/index.html (last accessed February13, 2014)

15. Law NH, Ellis H. Exposure of the wound - a safe economy in the NHS. Postgrad Med J 1987;63:27–28 [PMC free article] [PubMed] [Google Scholar]

16. Phan M, Van der Auwera P, Andry G, Aoun M, Chantrain G, Deraemaecker R, et al.. Wound dressing in major head and neck cancer surgery: a prospective randomised study of gauze dressing vs sterile Vaseline ointment. Eur J Surg Oncol 1993;19:10–16 [PubMed] [Google Scholar]

17. Merei JM, Jordan I. Pediatric clean surgery wounds: is dressing necessary? J Pediatr Surg 2004;39:1871–1873 [PubMed] [Google Scholar]

18. Vermeulen H, Ubbink DT, Goossens A, de Vos R, Legemate DA. Systematic review of dressings and topical agents for surgical wounds healing by secondary intention. Br J Surg 2005;92:665–672 [PubMed] [Google Scholar]

19. Ubbink DT, Vermeulen H, Goossens A, Kelner RB, Schreuder SM, Lubbers MJ. Occlusive vs gauze dressings for local wound care in surgical patients: a randomized clinical trial. Arch Surg 2008;143:950–955 [PubMed] [Google Scholar]

20. Brölmann FE, Eskes AM, Goslings JC, Niessen FB, de Bree R, Vahl AC, et al.; REMBRANDT study group. Randomized clinical trial of donor-site wound dressings after split-skin grafting. Br J Surg 2013;100:619–627 [PubMed] [Google Scholar]

21. Heal C, Buettner P, Raasch B, Browning S, Graham D, Bidgood R, et al.. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ 2006;332:1053–1056 [PMC free article] [PubMed] [Google Scholar]

22. Brandt MG, Moore CC, Conlin AE, Stein JD, Doyle PC. A pilot randomized control trial of scar repigmentation with UV light and dry tattooing. Otolaryngol Head Neck Surg 2008;139:769–774 [PubMed] [Google Scholar]

23. Due E, Rossen K, Sorensen LT, Kliem A, Karlsmark T, Haedersdal M. Effect of UV irradiation on cutaneous cicatrices: a randomized, controlled trial with clinical, skin reflectance, histological, immunohistochemical and biochemical evaluation. Acta Derm Venereol 2007;87:27–32 [PubMed] [Google Scholar]

24. Vermeulen H, Ubbink DT, Schreuder SM, Lubbers MJ. Inter- and intra-observer (dis)agreement among nurses and doctors to classify colour and exudation of open surgical wounds according to the Red-Yellow-Black scheme. J Clin Nurs 2007;16:1270–1277 [PubMed] [Google Scholar]

25. Fletcher J. Wound bed preparation and TIME principles. Nursing Standard 2005;30:57–65 [PubMed] [Google Scholar]

26. ADAPTE Collaboration. Guideline adaptation: a resource toolkit. 2009. www.g-i-n.net/document-store/working-groups-documents/adaptation/adapte-resource-toolkit-guideline-adaptation-2–0.pdf (last accessed March5, 2014)

27. Brölmann FE, Groenewold MD, Spijker R, van der Hage JA, Ubbink DT, Vermeulen H. Does evidence permeate all surgical areas equally? Publication trends in wound care compared to breast cancer care: a longitudinal trend analysis. World J Surg 2012;36:2021–2027 [PMC free article] [PubMed] [Google Scholar]

28. Brölmann FE, Ubbink DT, Nelson EA, Munte K, van der Horst CM, Vermeulen H. Evidence-based decisions for local and systemic wound care. Br J Surg 2012;99:1172–1183 [PubMed] [Google Scholar]

29. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies—a synthesis of systematic review findings. J Eval Clin Pract 2008;14:888–897 [PubMed] [Google Scholar]

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Overview of the recommendations

Wound cleansing and antisepsis

1. The cleansing of primarily closed wounds is dissuaded.

2. Dirty open wounds (street, bite, or cut wound) should be cleansed.

3. If a wound needs cleansing, then drinkable tap water suffices. This should be applied in a patient-friendly way using lukewarm water and a gentle squirt.

4. The use of disinfectants to cleanse acute wounds is dissuaded.

5. Bathing of wounds in whatever solution, even water, should not be part of wound cleansing.

Pain control

6. Consider psychosocial, local, and systemic forms of analgesic treatment.

7. Use the WHO pain ladder when considering a systemic analgesic treatment. Any prescription should be in agreement with the patient's preference.

8. The use of NSAID-containing dressings to treat continuous wound pain is dissuaded.

9. Lidocaine or prilocaine is considered the first-choice drug to avoid acute-wound pain during manipulation or surgical closure.

10. Lidocaine or prilocaine should preferably be administered as infiltration anesthesia.

11. EMLA® cream should be applied for indications as defined in the instruction leaflet: intact skin, genital mucosa, or crural ulcers.

12. When the patient is afraid of needles, lidocaine or prilocaine might be administered cutaneously, but be aware of the time to take effect (30–45 min).

13. Mild and moderate pain (VAS or NRS score between 1 and 6) can best be treated with paracetamol and an NSAID.

14. In high-risk patients (e.g., above 70 years of age) the prescription of NSAIDs is dissuaded.

15. If the first two steps of the WHO ladder do not suffice to treat moderate-to-severe pain (VAS or NRS score between 3 and 7), then use a strong-acting opioid (step 3).

16. Prescribe only one strong-acting opioid per healthcare institution and carry a limited range of these opioids in stock.

Instructions to the patient

17. The application of wound dressings on primarily closed wounds is dissuaded. A dressing may be considered

a. To absorb exudate or transudate.

b. In case the patient prefers this, after being informed it will not prevent a wound infection and may hurt when being removed or changed.

18. Showering the wound area (for <10 min) is allowed 24 h after surgical wound closure in a hospital, if the patient wishes to do so.

19. If there is a prosthesis beneath the wound, then showering the wound area (for <10 min) is allowed after 48 h if there are no signs of infection and the treating surgeon agrees.

20. The treating surgeon should instruct patients about when and how to mobilize. This may depend on the patient's preference, location of the wound, healing progress, and type of surgery performed.

21. Patients should be advised to protect superficial wounds (e.g., grazes) against exposure to ultraviolet light for at least 3 months.

Wound care materials

22. Covering a primarily closed wound using a simple dressing material is indicated only in case of wound leakage, to protect against adherence of the wound to clothes, or if the patient so wishes, for example, when he does not want to see the wound.

23. For wounds healing by secondary intention, a nonadhesive dressing should be applied. The choice of dressing should be determined by the patient's circumstances (e.g., change frequency, leakage, or pain).

24. For donor-site wounds after split-skin grafting, a hydrocolloid is advised to promote wound healing, while a film dressing is a good alternative.

25. A locally infected wound may be treated with iodine or honey, after adequate cleansing. As none of the antiseptics excels, iodine or honey is recommended. The choice may be based on product availability, experience with and knowledge about the product, and their discerning characteristics.

26. In future studies on antiseptics, iodine or honey should be one of the study arms.

27. Leaking wounds deserve an absorbing dressing that is changed depending on the amount of exudate. Additional absorbing capacity is required when leakage is expected to be substantial or when demanded by the patient's circumstances.

28. Prolonged or substantial leakage also calls for exploration of its cause.

29. In bite wounds, a nonadhesive or absorbing dressing is advised. Small bite wounds may dry and heal uncovered.

30. Patients with bite wounds should be instructed about signs of infection.

31. Superficial, nonleaking grazes may not need a dressing or be covered with paraffin or a plaster. Consider using an (semi) occlusive dressing if the wound is painful.

32. Leaking grazes may be covered with a nonadhesive dressing (paraffin gauze or silicone dressing) and an absorbing dressing.

33. Skin tears and flap wounds should be covered, after appropriate cleansing and fixation of the detached skin, with a nonadhesive dressing, which should preferably not be changed within 7 days. If a skin flap is resected, then a nonadhesive dressing should be used that should remain in situ as long as possible.

Organization of acute-wound care

34. To classify the status of the wound, the Red-Yellow-Black scheme can be used, including the assessment of the wound moistness (wet, moist, or dry).

35. In addition to the RYB scheme, the TIME model is recommended to facilitate a uniform and systematic wound care policy.

36. To ensure continuity in the chain of care, the following wound care aspects are vital to be recorded in writing, preferably by a wound care specialist, and to be handed over in case of referral.

a. Wound characteristics

b. Patient characteristics (e.g., comorbidity)

c. Diagnosis and treatment plan

d. Goals to be reached

e. Tasks and responsibilities of caregivers involved

f. Indications when to refer and to whom

g. Who has performed the treatment and who is responsible

37. Drugs for patients with acute wounds may be prescribed by physicians, nursing specialists, or physician assistants, according to prevailing legislation.

38. The wound care policy should only be performed by qualified and capable professionals.