Debridement Flashcards
1
Q
As tissues die, they change…
A
- Color (darken)
- Consistency (dry, leathery, hard)
- Adherence to the wound bed (increases)
2
Q
As necrotic tissue increases in severity color changes from…
A
White/grey -> tan/yellow -> brown/black
3
Q
Necrotic fat tissue forms
A
String, yellow/brown slough
4
Q
Necrotic muscle tissue
A
Degenerates into thick, tenacious tissue
5
Q
Hard black eschar =
A
Full-thickness destruction
6
Q
Grey/blue or white devitalized tissue may represent…
A
Prolonged ischemia
7
Q
Slough
A
- Yellow or tan
- Thin, mucinous or stringy
8
Q
Eschar
A
- Brown or black
- Soft or hard
- Represents full-thickness destruction
- The MORE water content present, the LESS adherent the debris is to the wound bed
9
Q
Adherence
A
- Represents the adhesiveness or debris
- Ease at which the two are separated
- Necrotic becomes more adherent to the wound as level of damage increases
- Eschar > yellow slough
10
Q
Necrotic tissue
A
- Slows wound healing -> acts as a physical barrier to epidermal resurfacing, contraction, granulation
- Medium for bacterial growth (allows)
- Greater amount = more healing time
- Obscures visualization of the total wound
11
Q
Necrotic tissue in arterial/ischemic wounds
A
- May appear as dry gangrene
- Thick, dry, desiccated, black/gray appearance
- Firmly adhered to wound bed
- May be surrounded with red halo as body attempts to get blood to the area
12
Q
Neurotrophic wounds
A
- Usually no necrosis
- But often have hyperkeratosis (callus) surrounding the wound edges
13
Q
Necrotic tissue in venous disease wounds
A
- Either eschar or slough
- Yellow fibrinous material cover the wound
- Eschar may be due to desiccation and or necrotic debris
14
Q
Necrotic tissue in pressure sores
A
- Relates to amount of tissue destruction
- Early stage of ulcer tissue may appear hard (indurated) with purple or black discoloration on intact skin (indicative of tissue death)
15
Q
Idea behind wound debridement
A
- Prevents bacteria from colonizing
- Prevents competition with viable cells for oxygen and nutrients
- Removal of necrotic and/or infected tissue that interfere with wound healing
16
Q
Reported to be the most effective method of controlling wound colonization
A
Debridement and irrigation
17
Q
Appropriate wounds/indications for debridement
A
- Partial or full-thickness wounds
- Necrotic tissue (eschar, slough)
- Foreign material
- Debris
- Residual topical agents
- Blisters
- Callus
18
Q
With debridement, wounds get…
A
Bigger before they get better!
19
Q
Do not debride
A
- Granular tissue
- Viable tissue
- Stable heel ulcer (“the black heel”)
- Gangrene, osteo
- Pyoderma gangrenosum (infection)
- Electrical burns (deep)
- Deeper tissues (muscle, tendon, ligament, bone, nerves, blood vessels)
- Patients with impaired clotting mechanisms**
20
Q
Caution must be exercised when debriding a wound of a patient on
A
Anticoagulants
21
Q
Debridement is contraindicated…
A
- Of dry eschar over a bone or tendon
- In the presence of dry gangrene
22
Q
Note that the periwound tissue is
A
Adequately perfused with blood
23
Q
Benefits of wound debridement
A
- Decrease bacteria within the wound bed, decreasing risk for infection
- Increase effect of topical antimicrobials
- Improve effect of inflammatory cells
- Decrease length of inflammatory phase
- Decrease the metabolic expense for healing
- Decrease physical barrier to healing
- Decrease odor of the wound
24
Q
Definition of debridement
A
Removal of necrotic and extraneous (foreign material, debris) tissue from the wound
25
26
Non-selective debridement
- Removing tissue that could be harmful or helpful to healing process (all cell types)
- Mechanical debridement:
- Dry to dry; most damaging ie. Dry gauze into wound and remove
- Wet to dry; wet gauze into wound & let it dry out, then remove
- Wet to wet; least damaging ie. Wet gauze into wound bed, wet before removing
- Dakin’s solution
- Hydrogen peroxide
- Whirlpool
- Irrigation/lavage
27
Selective debridement
- Selecting what tissues are removed
- Autolytic debridement
- Enzymatic debridement
- Sharp/surgical debridement
28
Autolytic debridement
- Selective debridement method
- Use of body’s own endogenous enzymes
- Apply a moisture retentive dressing/transparent film
- Wound fluid trapped beneath the dressing softens and liquefies necrotic tissue
- Growth factors and inflammatory cells may enhance healing as well
- Least invasive, least painful method
29
Contraindication for Autolytic debridement
Infected wounds
30
Enzymatic debridement
- Form of selective debridement
- Indicated for infected and uninfected wounds with necrotic tissue via use of topical exogenous enzymes to remove devitalized tissue
- Enzymes can be used with topical antimicrobial therapy (Polymoxin B with collagenase) infected wounds
- Best for softening large necrotic areas (collagenase - Santyl is the only FDA approved tx)
- Requires physicians order
- Discontinue use after 2 weeks if necrotic tissue is not effectively reduces**
31
Contraindications for enzymatic debridement
Wounds with exposed deep tissues (ligament, tendon, capsule, bone, nerve, muscle, blood vessels)
32
Pulsatile lavage with suction (PLWS)
- Non-selective form of debridement
- Debrides by hydropressure and concurrent vacuum (normal saline)
- Irrigation between 4-15 psi, generally 8-12 psi
- Tunnels treated with lower pressure 2-6 psi
- Must occur in private room with walls and doors that close (no curtained area)
- Single use only!
- Microorganisms can be found as far as 8 ft from tx area
33
Sharp debridement
- Selective form of debridement
- Removal of nonviable tissue with sterile instruments (scalpel, forceps, scissors)
- Physicians, nurses, PA, & PTs able to perform
- All PT practice acts are written broadly enough to allow PT’s to perform wound debridement without restriction
- PTA’s cannot perform sharp debridement
- Two types: selective sharp and serial
34
Indications for sharp debridement
- Large amount of necrotic tissue
- Advancing cellulitis or sepsis (infection is NOT a contraindication)
- Thick adherent eschar
35
Serial (sharp) debridement
- Forceps and scissors
- Occurs over several visits
- Creates minimal bleeding
- Usually requires softening necrotic tissue, making it more amendable to debridement, by use of whirlpool, irrigation, or pulsatile lavage
- Goal is to remove loosely adherent necrotic tissue
36
Selective sharp debridement
- Uses scissors and/or scalpel
- Cut along the border of viable & non-viable tissue
- Usually does not require prior tissue preparation
- Gelfoam or silver nitrate may be needed to control minimal bleeding (requires prescription)
37
Termination of sharp debridement
- Clinician becomes fatigued
- Patient reports increased pain
- Patient is less tolerant to procedure
- Bleeding beyond minimal
- A new fascial plane is identified
- All necrotic tissue has been removed
38
Maggot debridement therapy
- Sterile larvae from common green bottle fly
- Selectively ingest necrotic tissue and excrete proteolytic enzymes
- 10 larvae per cm^2, left in wound for 1-3 days
- Effective for debriding pyoderma gangrenosum for which sharp debridement is contraindicated
39
Contraindication for maggot debridement therapy
- Severe infection
- Inadequate blood supply
- Pts with increased bleeding risk
40
Surgical debridement
- Performed by physician or podiatrist
- Scalpels, scissors, or lasers used
- Performed in sterile environment
41
Indications for surgical debridement
- Ascending cellulitis
- Osteomyelitis
- Extensive necrotic wounds
- Wounds with extensive undermining or where undermining cannot be determined
- When necrotic tissue is near a vital organ
- When the patient is septic
