Nursing interventions to reduce surgical site infection in potentially contaminated surgeries: an integrative review TO

Objective: Identify nursing interventions that contribute to the reduction of surgical site infections in potentially contaminated surgeries. Methods: Integrative review, carried out in four databases. There were 5,888 articles published in the period from January 2008 to July 2018, in English, Portuguese and Spanish, from which nine articles were selected after final analysis. Results: The nursing interventions appeared according to the perioperative periods: preoperative (55.55%), intraoperative (33.33%), postoperative (66.66%), being associated with: antibiotic therapy, trichotomy, alcoholic chlorhexidine bathing, hand hygiene, sterile glove/wear/ package change for fascia and skin closure, degermination, antisepsis, surgical classification, surgical time, care with dressings and drains, temperature and blood glucose control, patient education, discharge and post-hospital discharge orientation. Conclusions: Nursing interventions were identified in each perioperative period, proving to be essential for the qualification of nursing care and effective in reducing surgical site infection in potentially contaminated surgeries. DESCRIPTORS: Nursing. Perioperative nursing. Patient safety. Enterostomal therapy.


INTRODUCTION
Surgical site infection (SSI) is one of the main complications after the surgical procedure 1 . The SSIs are defined as an infectious process that affects tissues, organs and cavities, and can be present in any type of surgical procedure 2,3. Although references indicate that the SSIs occur in any type of surgical procedure 2,3 , the occurrence is greater in surgeries classified as potentially contaminated1.
Potentially contaminated surgeries are those performed on tissues with the resident flora not numerous or where decontamination is a difficult process 4 .
In Brazil, the SSIs correspond to 14 to 16% of adverse events, occupying the third position among infections that occur in hospitalized patients 3 . In addition, they are responsible for increased morbidity, mortality and high hospital costs due to increased length of stay and health care costs 1
assistance procedures and surgical techniques adopted.
The importance of the identification of these factors by the health team is given by the fact that most of the extrinsic factors can be avoided by actions of care, which are of entire responsibility of the care team that assists the patient 1,6 .
As a member of the health team, the nurse and the nursing team are also prominent in this situation, being considered essential for the care of the patient in a surgical health condition, since at this time patients need specific attention, care and guidance, due to the mixture of feelings such as fear, anxiety and doubts 1,7 .
Nursing is then responsible for receiving and assisting the patient during the perioperative period by systematizing nursing care, with implementation of the nursing process with which it is possible to establish nursing interventions 7 .
The implementation of these nursing interventions with a focus on preventive measures, as well as their adequate implementation, has a significant impact on the reduction of SSI and its dissemination 1 .
Due to the significant burden in terms of morbidity and mortality together with the increased length of stay that SSIs cause, generating additional costs for health systems and service providers worldwide, knowledge of nursing interventions can positively interfere with health practices and is a relevant theme for this study 8 .
Given the context of SSI for professional practice, there was a need to seek the nursing interventions that contribute to the reduction of SSIs in potentially contaminated surgeries, in order to contribute to the dissemination and updating of information that is scientifically proven in recent studies.

OBJECTIVE
Identify the nursing interventions that contribute to the reduction of SSIs in potentially contaminated surgeries.

METHODS
Integrative review (IR) carried out from the elaboration of a protocol according to Whittemore and  In the fourth stage, similar information was sorted, coded, categorized, summarized, compared and grouped.

RESULTS
Initially, 5,888 articles were selected, 2,092 of which were excluded due to duplicity or impossibility of complete visualization, reaching a total of 3,796 articles for preselection, of which 28 were read in full and evaluated by the application of SQUIRE 2.0, resulting in 9 articles in the final result.
The sequence of this identification, selection and inclusion of the articles is presented in Fig. 1       The results of the selected articles are presented in Table 3. Table 3. Description of the articles according to the results of the articles -Florianópolis, SC, Brazil. 5

N. Result
The SSI occurred in 6.3% of the cases, with a predominance of superficial infections (83.3%). Of the infections, 76.5% did not obtain nursing guidance mainly related to the care of the surgical wound (89.7%). The failure in the nursing guidelines for the prevention of SSI was highlighted, evidencing the need for a method of post-hospital discharge surveillance that allows the identification and notification of cases, reducing the underreporting of cases 18 .

6
Preoperative bathing with 2% gluconate chlorhexidine cloths generates an overall reduction of infection from 6.3 to 2.1%, including space and organ infections 13 .

7
The foam dressing with transparent film brings benefits and reduces the risks of SSI, having 0% of infection in the study carried out, because it allows the protection of the skin together the visualization and evaluation of the perilesional skin by the nurse, allowing its permanence for 48 h in the postoperative, even after the bath 12 . 8 Nursing care focused on risk factors may have repercussions on the reduction of the occurrence of SSI, these cares refer to: degermination and antisepsis, trichotomy with razor blade, type of surgery with emphasis on those classified as potentially contaminated surgeries, surgical risk ASA II, surgical time, use of antibiotic therapy and care with drains and dressings 19 . 9 In the group in which the chlorhexidine bath was not applied, the risk of infection was 4.76 times higher, even after age and sex corrections, showing the importance of preparing the skin by bathing with degermating chlorhexidine before surgery 11 .
Nursing interventions and preoperative phase guidelines were evidenced in five (55.55%) 11,13,15,18,19 articles, highlighting hand hygiene in one (20%) 15 article; trichotomy without razor, only when necessary in three (60%) 11,15,19 ; bath with alcoholic chlorhexidine in four (80%) 11,13,15,18  In the case of the health education process and nursing guidance on the prevention of SSI either preoperatively, postoperatively or at hospital discharge were evidenced in two articles (22.22%) 15,18 , as well as home follow-up to patients and family members 15,18 . Of these, surveillance after hospital discharge to minimize underreporting rates was addressed in one (50%) article 18 .

DISCUSSION
The SSI is one of the most common health-related infections in the hospital environment, and is also the most frequent complication in surgical patients. Despite the advance in technologies, methods and resources for health care, this reality still persists in hospitals in Brazil1. This type of infection is still a concern of health professionals due to its consequences in the economic sector, both for the institution and for biopsychosocial issues, as well as the fact that its occurrence is directly related to the behavior of professionals during their health actions 20,21 , in addition to noncompliance with recommended actions, since they are infections that can be avoided1.
The evaluation of the health professional is essential for the perception of factors that can trigger and prevent SSI, because the knowledge of risk factors serves as a measure to reduce its occurrence 1,22 . Taking into account that the nursing team is the profession that spends the longest period in direct care with the patient and has technical-scientific competence to perform the perioperative care, besides assuming a primordial role in the control of hospital infections 23 .
The nursing interventions found in the IR data search for the preoperative period are: bath and skin preparation 11,13,15,18 , trichotomy 11,19, antibioticoprophylaxis 15,18,19 and surgical hand antisepsis 15 , use of sterile gauzes in individual packs 17  Intraoperative nursing interventions are associated with surgical environment 15,18,19 , surgical antisepsis of the hands with degermating antiseptic or alcohol-based product 15,19, potential for contamination of operative wound 18,19 , surgical duration 19 and sterile glove replacement 15  The glycemic control 14