Debridement Flashcards
What can be defined as the removal of necrotic tissue, foreign material, and debris from the wound bed?
Debridement
What are the 2 forms of Debridement?
- selective
- nonselective
What are 5 risks of not debriding?
- infection
- osteomyelitis
- sepsis
- amputation
- death
What are the 7 purposes of debridement?
- decrease bacterial concentration within the wound bed and the risk of infection
- increase the effectiveness of topical antimicrobials
- improve the bactericidal activity of leukocytes
- shorten the inflammatory phase of wound healing
- decrease the energy required by the body for wound healing
- eliminate the physical barrier to wound healing
- decrease wound odor
When determining appropriate interventions in regards to debridement what is the general rule to follow?
the red-yellow-black system
If the wound bed appears pale pink to beefy red and granulation tissue is present, what should you do?
protect the wound, maintain a warm and moist environment, and protect the periwound area.
If the wound bed appears moist and yellow, what should you do?
debride the necrotic tissue, absorb any drainage, and protect the periwound area
If the wound bed appears thick, black, and there is adherent eschar present, what should you do?
debride the necrotic tissue
Under what 3 circumstances should blisters be debrided?
- large, fluid filled blisters
- blisters over joints
- burn blisters
Why should calluses be debrided?
to eliminate localized areas of increases pressure
What are the __ general contraindications for debridement?
- if the wound is red and granular in appearance
- heel ulcers with dry eschar if they do not have edema, erythema, fluctuance, or drainage
- wound that require surgical debridement
- electrical burns prior to physician assessment
What are 4 things the clinician must take into consideration when determining whether debridement is appropriate and what methods to use?
- Characteristics of wound
- Status of patient
- Existing practice acts
- Clinician’s knowledge and skill level
Describe the step-by-step guide for preparing for debridement
1) assemble equipment and supplies that may be needed
2) position the patient comfortably, allowing for visualization of the wound bed
3) use proper posture and body mechanics to allow safe technique and minimize fatigue
4) ensure sufficient lighting of the involved area
5) wash hands and don clean gloves
6) remove the old bandage and discard according to facility policies
7) discard soiled gloves and apply clean gloves
8) inspect the wound to determine if debridement is necessary and, if so, what method is most appropriate
9) remove soiled gloves
10) explain the procedure to the patient
11) don clean gloves and initiate debridement technique
What are the 6 methods of debridement?
- Sharp
- Autolytic
- Enzymatic
- Mechanical
- Biological
- Surgical
Describe sharp debridement
It is the fastest and most aggressive form of debridement in which the clinician uses forceps, scissors, or scalpel to selectively remove devitalized tissue, foreign material, and debris
Who is allowed to perform sharp debridement?
PTs when allowed by law, however it requires a MD order
What are the 3 indications for sharp debridement?
- Large amount of necrosis, callus, advancing cellulitis, sepsis, eschar
- May be used on wounds with any amount of necrotic tissue
- Chronic wounds
What are the 7 contraindications to sharp debridement?
- When the area cannot be adequately visualized because of extensive tunneling and undermining
- Material to be debrided is unidentified
- Lack of clinician competency
- Uninfected ischemic ulcers with low ABIs
- Patients who are immunosuppressed, thrombocytopenic, or on anticoagulants
- Wound closure is not consistent with the POC
- Hypergranular tissue is present
What are the 6 conditions in which sharp debridement should be terminated?
- Clinician fatigues
- Pain is not adequately controlled for patient
- Decline in patient status or tolerance to technique
- Extensive bleeding
- If a new fascial plane is identified
- Nothing remaining to debride
What are the 2 types of sharp debridement according to the APTA?
- Serial instrumental debridement
- Selective sharp debridement
Describe serial instrumental debridement
Form of sharp debridement in which instruments are used to remove loosely adherent necrotic tissue with minimal bleeding and is typically pain free
What is serial instrumental debridement oftentimes referred to as?
maintenance debridement
Who can perform serial instrumental debridement?
- physician
- podiatrist
- PT
- PTA
Describe selective sharp debridement
Form of sharp debridement in which scissors or a scalpel are used to cut along the line of demarcation between the viable and nonviable tissue.
What is the biggest difference between serial instrumental and selective sharp debridement?
selective sharp is typically very painful and requires pain management and hemostatic agents to control bleeding. Whereas serial instrumental debridement is pain and blood free.
Who can perform selective sharp debridement?
- physician
- podiatrist
- PT
Describe the step-by-step procedure to sharp debridement
1) prepare the patient for debridement
2) explain the specific procedure to the patient
3) open necessary equipment and supplies
4) for selective sharp debridement, silver nitrate sticks and/or an absorbable gelatin sponge should be available
5) ensure adequate pain control
6) don clean gloves
7) identify devitalized tissue, foreign material, and debris to be debrided
8) remove as much of these tissues/material as possible applying tension and using a layered approach
9) rinse the wound with saline
10) assess changes in wound status and perform any necessary wound measurements
11) dispose of sharp instruments and infectious waste
12) remove and dispose of soiled gloves
13) don clean gloves
14) apply wound dressing
15) remove and dispose of soiled gloves
16) initial and date wound dressing
17) wash hands
18) provide any necessary posttreatment instructions
19) complete documentation
What is the key to performing sharp debridement?
ensure that the scalpel and scissors are PARALLEL to the surface when debriding
Which form of debridement is the least invasive and the least painful?
Autolytic
Describe Autolytic debridement
Uses the body’s own (endogenous) enzymes to digest necrotic tissue by applying a moisture-retentive dressing, such as hydrogel, semipermeable foam, or hydrocolloid, and leaving it in place for several days
What are the indications for autolytic debridement?
- All wounds with necrotic tissue
- Patients who cannot tolerate other forms of debridement
- Commonly used in home or long-term care settings
What are the 2 contraindications to autolytic debridement?
- Infected or deep cavity wounds
- Wounds that require sharp or surgical debridement
What are the 2 conditions in which autolytic debridement can be terminated?
- favor of alternative methods
- if necrotic tissue fails to decrease in expected amount of time (2 weeks)
What is an important first step to autolytic debridement when eschar is present?
Crosshatch the eschar with a scalpel
How large should the moisture-retentive dressing be in comparison to the wound?
approximately 2 cm larger
How long does the dressing stay on during autolytic debridement?
72-96 hours
What is imperative to protecting the periwound area?
apply a skin sealant to prevent maceration or fungal infection
What is enzymatic debridement?
the use of a topical exogenous enzyme to remove devitalized tissue
What are the 3 main types of substrate-specific exogenous enzymes?
- proteolytics
- fibrinolytics
- collagenases
*Collagenase is the only enzyme currently FDA approved
What are the pros and cons to enzymatic debridement?
- Requires less skill than sharp or surgical debridement
- Less painful than other methods
- Can be expensive
What are the 3 indications for enzymatic debridement?
- Infected and uninfected wounds with necrotic tissue
- Patient cannot tolerate sharp debridement
- Appropriate in-home or long-term care
What are the 5 contraindications to enzymatic debridement?
- Wounds being autolytically debrided
- Wounds with exposed deep tissues
- Facial burns
- Calluses
- Wounds free of necrotic tissue
When should enzymatic debridement be terminated?
- Once satisfactory debridement has occurred
If necrotic tissue fails to decrease in expected amount of time
Similar to autolytic debridement protocol what is a necessary first step to enzymatic debridement when eschar is present?
crosshatch the eschar
What are the 3 forms of nonselective debridement?
- mechanical
- biological
- surgical
Describe mechanical debridement
Involves the use of force to remove devitalized tissue, foreign material, and debris from a wound bed
What are 7 examples of mechanical debridement?
- wet to dry dressings
- scrubbing
- wound cleansing
- wound irrigation
- pulsatile lavage
- whirlpool
- hydrogen peroxide
Describe how wet to dry dressings work
Apply a single layer of fluffed saline-moistened gauze to a necrotic wound, covering with more gauze, and then allowing the dressing to dry for 8-24 hours. As the dressing dehydrates, the gauze adheres to the wound bed, trapping wound exudate and debris within the interstices. When the dressing is dry, it is torn away at a right angle from the wound surface, thus lifting any material adhering to the gauze off of the wound bed.
What is the only condition in which wet to dry dressings are indicated?
wounds with 100% devitalized wound bed
What are the recommendations for wound scrubbing?
Use a high-porosity sponge and as little force as possible to minimize trauma
What type of wounds is scrubbing best used for?
highly contaminated superficial wounds such as road rash
Define wound cleansing
The delivery of a wound cleanser to the wound surface using mechanical force to remove lightly adhered necrotic tissue, debris, and bacteria
What is a wound cleanser?
A commercially available solution that commonly contains surfactants, substances that lower the surface tension of loose particulate matter on the wound bed
What are the drawbacks to wound cleansing?
- it is not FDA regulated
- it is nonselective
- not efficient at debriding partial or full-thickness wounds
In wht type of wound may wound cleansing be used/considered?
- pressure ulcers with debris, infection, or high bioburden
- May be indicated for acute, minor integumentary injuries
Can wound cleansing be used for a long period of time?
No
What is biological debridement?
the use of maggots to debride necrotic tissue
What is an advantage that biological debridement has over autolytic and enzymatic debridement?
It is faster
When is surgical debridement indicated?
- in the presence of ascending cellulitis and/or osteomyelitis
- extensive necrotic wounds
- wounds with extensive undermining
- when necrotic tissue is near vital organs and structures
- when the patient is septic
- presence of gas gangrene
What are the 2 contraindications for surgical debridement?
- Patients who are unlikely to survive procedure
- Patients with palliative care plans
Describe the basic procedure behind surgical debridement
Tangential excision of eschar by sequentially shaving with a dermatome until healthy vascular tissue is reached.
If deep space infection is suspected then incision and drainage must be performed.
