Debridement and Dressings Flashcards
What is the ultimate goal of wound management
Full wound closure!
What are the most effective methods for controlling wound colonization? (2)
Debridement and irrigation
What is the interim step of wound management?
Obtain a clean, moist, warm, granular wound bed while protecting the periwound and intact skin
How do you maintain moisture balance?
Primarily through dressings
Is necrotic tissue a medium for bacterial growth?
Yes. It is also a barrier to wound contraction, granulation, and re-epithelialization
What is the rating (0-4) for a palpable pulse?
2+. User doppler, MRA, or angiogram if you have to. Listen for type of sound too
What meds must you find out if the patient is on before debridement?
Anticoauglants
Also check if infection is present?
Should you debride if non-viable tissue is present?
Yes, if slough or eschar is noted. Do not if it is all healthy tissue
Should you debride a dry, stable, uninfected would in the heel?
No
What do you ask yourself after determining the wound is in another location other than the heel?
Is sharp debridement appropriate?
If sharp debridement is NOT indicated, then what 2 questions must you ask yourself?
Is the wound infected?
Is the wound covered completely (100%) by non-viable tissue?
What debridement do you do if the wound is infected?
You do enzymatic debidement (autolytic debridement is CONTRAINDIATED!) *if it is not infected, then you can do autolytic
What debridement do you do if the wound covered completely (100%) by non-viable tissue??
Mechanical debridement is OK. If there is viable tissue present, consider ezymatic (infected) or autolytic (non-infected)
When can you NOT use enzymatic debridement?
If deeper tissues are exposed (bone, ligament, tissue)
What are the 7 contraindications to sharp debridement? (others Kathy Leahy listed in a separate slide are also listed)
Cannot visualize wound bed (tunneling, undermining, etc) Uninfected ischemic ulcers Connective / structural tissues Patient has poor tolerance (pain, agitation) Patient is taking anticoagulants Too much risk to viable tissue Practitioner not competent/not skilled in sharp debridement, or not allowed to perform by law --- Ischmeic tissue Wound bed not visible (tunneling) Deeper tissue Surgical debridement imminent Electrical burns (Sue Reeder) Protective eschar Pyogderma gangenosum - body attacks itself; looks life ulcer;treat w/steroids Confusion, agitation Precaution:anticoagulation meds Precaution:Low platelet counts
Should wounds get bigger before they get better?
Yes, they may still get bigger even after you treat it. Must document wound size progression to get reimbursed. But bleeding in sharp debridement should me minimal; it’s dead.
What is sharp debridement appropriate for?
Appropriate for wounds with eschar, loose slough, or adherent fibrin. Speed is an advantage, but anything sharp may cause damage to unintended structures
What instruments are used in sharp debridement?
Foreceps
Scissors
Scalpels
Curette - ice cream scoop
What might Pyoderma Gangrenosum be confused with?
Venous leg ulcer
1 in 100000
pts in 40s and 50s
What is the most selective form of debridement?
Autolytic
How does autolytic debridement work?
Uses body’s own enzymes to digest necrotic tissue (enzymes released by macrophages and neutrophils)
Use of moisture retentive dressing
How long does dressing cover wound bed in autolytic debridement? What are 3 examples?
SEVERAL DAYS! Examples include: Hydrogel sheets, hydrocolloids, transparent films (tegaderm (use over IV site) is most transparent and duoderm is least transparent)
What is the minimum amount of time to keep a hydrocolloid on?
3 days minimum for hydrocolloids
What takes longer, sharp debridement or autolytic?
Autolytic. 6 days longer than sharp
When is autolytic debridement contraindicated?
If wound is infected or covered with dry gangrene
use enzymatic if infected
What is the most clinically supported topical agent for debridement? (will be on test and NPTE per Kathy Leahy)
Enzymatic debridement (requires physician level script)
What are types of topical agents for enzymatic debridement?
Collagenase: digest necrotic collagen / deeper (e.g. Santyl)
Protease: digest protein tissue / superficial (will not harm live protein, only denatured ones)
Fibrinolysins: digest fibrin containing clots
Should you do enzymatic debridement for draining wounds?
No, it will wash right off.
How do you apply ezymatic debridement?
Prepare wound bed first, then apply exogenous enzymes
USE TO PRODUCT SPECIFICATION and discontinue when wound is clean with red granulation tissue
What does cross-hatching do during enzymatic debridement?
Gaps in eschar allow ointment to soak into surface
What is maggot therapy?
“Very graphic.” -Kathy Leahy, September 30, 2015
What is the benefit to wet-to-dry gauze dressings?
Inexpensive, but not favored
How does Soft debridement/Wound scrubbing work?
Semi-selective removal of moist, non-adherent necrotic tissue
What is used for Soft debridement/Wound scrubbing?
Gauze sponge or calcium alginate-tipped swab
When is Soft debridement/Wound scrubbing contraindicated?
For adherent, dry necrotic tissue
What type of solution do you use for syringe irrigation (hydrotherapy)?
Saline or tap water
What PSI do you use for irrigation?
4-15 psi is appropriate but 10-15 psi is most effective
When is irrigation contraindicated?
Only for wounds with profuse bleeding
What equipment can be used for irrigation? (3)
Syringe w/ needle
Canyons Wound Irrigation System (syringe system w/o needle)
Pulsed Lavage with or without suction
What is the most common type of hydrotherapy used in wound care?
Pulsed Lavage WITH suction
On what wounds can you use Pulsed Lavage with Suction?
Any type of wound (but can burst blood vessels). Shown to promote formation of granulation tissue
It is very versatile and like why it is the most common type of hydrotherapy used in wound care. Good for those with MRSA
Can you use Pulsed Lavage with Suction for tunneling?
Yes. It also provides non-selective debridement as well as cleansing and irrigation
Does Pulsed Lavage with Suction promote granulation tissue formation?
Yes, as mentioned earlier.
What PSIs do you use for Pulsed Lavage with Suction?
Tunnels 2-6 PSI
Most wounds 8-12 PSI
Infected wounds 12-15 PSI
What level of evidence does Whirlpool have?
Level C
What are 3 rationales for selecting whirlpool? (what does it do//why is it good?)
- Reduce wound contamination and infection by softening and removal of debris and exudate
- Increase local tissue perfusion
- Stimulate cellular activities for regeneration to facilitate neuronal mechanisms for analgesia for pain relief and increased mobility
What are 4 benefits of whirlpool?
Increase O2 transport
Increase nutrient transport
Remove waste products
Treat multiple wound sites at one time
What are contraindications to using whirlpool? (18)
Moderate to severe extremity EDEMA Lethargy Unreponsiveness Maceration Febrile conditions Traction Casted extremities ICU Obesity Compromised CV or pulmonary function Acute plebitis Renal failure Dry gangrene Incontinence Contractures Ostomies IV placements Combativeness/restraints
Precautions to whirlpool?
Clean, granulating wounds Epithelializing wounds New skin grafts New tissue grafts Non-necrotic diabetic ulcers Edematous limbs
Adaptations to whirlpool?
Reduce aeration or shut off (becomes soaking)
Change water temp
Change length of treatment time
Follow-up care post whirlpool - rinsing, sharp, debridement, compression wraps
What are considerations (disadvantages) to using whirlpool?
Infection control: cleaning of equipment practices and potentials
Time (set up, procedure, take down)
Disadvantages of soaking, dependent position, and transporting patient off IP units
Tank size and ability to submerge body part
Too much necrotic tissue - use alternative method
Do many facilities use whirlpools?
No
What 4 factors lead to the optimal environment for wound healing?
Moisture level (balance b/t wet and dry)
Bacterial control
pH
Temperature
Should you use enzymatic debriders on necrotic wounds?
Yes
What is Platelet Derived Growth Factor (REGRANEX)
VERY expensive and not easily reimburseable
Used as a catalyst for angiogenesis
Usually requires expensive, multi-layer daily dressings
Needs to be refrigerated
Use on clean, granulating wounds
What is the average pH of the blood?
7.1
What is the average pH of a wound
5.8-6.6
What can lower the pH in a wound? (4)
Urine, stool, fistula drainage, chemicals/topical agents
Do you want wound dressings to have a high or low pH?
Low, may facilitate wound healing.
What is a temperature of a wound relative to the body?
In absence of infection/other factors, wound have LOWER temps secondary to evaporative moisture loss
Do you want the temp of a wound to be warm or cold?
Warm! Colder temps lead to slower cell migration which lead to slower healing
How does an arterial wound present and what does it need?
Usually dry - needs moisture
How does a venous wound present and what does it need?
Usually wet - needs absorption
How does a diabetic wound present and what does it need?
Varies but often needs collagen
How does a pressure wound present and what does it need?
Needs pressure relief first then appropriate moisture
How does a surgical/traumatic wound present and what does it need?
Various needs
What dressing provides moisture, is generally changed daily, and needs a primary cover dressing over the gel?
Hydrogel
Examples: Nomrlgel, Woun’dres
What is a cross-linked polymer primary cover that is non-adherent and provides minimal absorption? This dressing may stay in place for 7 days, usually changed every other day (depends on the amount of dressing present)
Hydrogel sheets.
Examples: Clearsite, Nu-gel
What dressing covers and protects and usually has a petroleum base? This is a non-adherent primary cover dressing
Impregnated
Examples: Xeroform, Adaptic, Mesalt
What dressing is a sheet or foam, utilizes Safe-Tec technology and does not cause microtrauma to wound base with removal?
Silicones
Examples: Mepitel, Mepilex, Allevyn Gentle, Restore Contact Layer
What dressing non-absorptive and covers/protects? It is non-permeable to bacteria and other fluids, permeable to water vapor and gas, and may stay on for 7 days (depending on drainage)
Films/Transparent Adhesives
Example: Tegaderm
What is non-permeable in a film?
non-permeable to bacteria and other fluids
What is permeable in a film?
Water vapor and gas
What dressing is occlusive (good at sealing, not at absorbing), adheres to wound and surrounding tissues, and may stay in place for 5-7 days (or at least 3 days)?
Hydrocolloids
Example: Duoderm
What dressing provides min-mod absorption, can be a primary or secondary dressing, and leaves no residue in wound or on surrounding tissues?
Foams
Examples: Copa, Lyofoam
What dressing is made from seaweed or woven fibers, and offers mod-high absorption?
Calcium Alginate
Examples: Melgisorb, Fibracol, Maxorb
Are calcium alginate dressings used for infected or non-infected wounds?
BOTH!
How long should calcium alginate dressings stay on?
Change when saturated
Daily on infected wounds
Up to 7 days in non-infected wounds
What dressing offers high absorption and used as a primary dressing? It is expensive but can be cost effective if used correctly.
Hydrofiber
Example: Aquacel
What absorbs more, calcium alginate or hydrofiber?
Hydrofiber - 3x more than calcium alginate
How long can hydrofibers stay on?
1-3 days, but up to 7 days w/ Aquacel AG
What must you do before using a compression dressing?
Evaluate for a pulse!!!
How do compression dressings work?
Supports veins to return blood to the heart. Multiple layers
What are examples of Compression Dressings?
Unna boots, Profore, Coban 2 Layer
What dressing controls broad spectrum gram + and gram - microorganisms? There is a high up-front cost, can be cost-effective.
Antimicrobials
Examples: Aquacel-AG,, Silverlon, Kerlix AMD, Hydrofera Blue
How often do antimicrobials must be changes?
Changed daily to up to 7-14 days
What dressing provides a scaffolding matrix for cells to grow? Some have human cells and some have animal cells. There are a variety of products.
Bioengineered tissue
What bioengineered tissue has human cells?
Apilgraf
What bioengineered tissue has animal cells?
Oasis (the bar that’s full of animals, remember it.)
Spray-applied cell therapy?
Read the article.
What costs more, antimicrobial agents or systemic medications?
Antimicrobial agents
What two agents are in antibacterial dressings
007, jk
Bactericidial (death)
Bacteriostatic (inhbits growth (of the healthy bacteria?))
What are common antibacterial agents?
Bacitracin-zinc (sulfa-free) Gentamicin sulphate Metronidazole gel Mupirocin Polymycin B sulfate Silver sulfadiazine/Silvadene Neosporin
According to Kathy Leahy, with antibacterials, if you do not see progress by this time, you will never see progress:
5 days
What are common antifungal agents?
Myocostatin
Oxistat
Miconazole
For what kind of wounds do you need topical agents?(think very generally)
For cleansing a dirty wound (slough, necrosis, contaminated). Clean wounds and beefy red wounds (and dirty wounds) can be cleaned with normal saline, tap water, and VASHE. Use the least traumatic method possible!
Why should you not use cleansing agents?
They are cytotoxic to healing tissues; they destroy the cell membrane and delay healing.
When would cleansers be appropriate?
If the wound is covered with necrotic tissue and is already non-viable
How long are topical agents used and what are they used for?
Used for less than 2 weeks. They are used to decrease bacterial burden, cleansing, and chemical is selected based upon bacterial organism
What is VASHE?
Hypochlorous acid (0.033%)
What is Dakins?
Diluted bleach, used during WWI for infections
What is the recommended concentration of Dakins?
1/16
What is the most common concentration of Dakins?
1/8
What is Acetic Acid primarily used for?
Primary use is Pseudomonas. Most common concentration is 0.25%. Strong odor of Vinegar
What is a popular strong broad-spectrum topical microbicide (10% providone-iodine)? Most commonly used to manage dry, black, non-infected arterial wounds where surgical intervention is not recommended (stable eschar)
Betadine
What dressing/agent is most commonly used for the effervescence properties to lift debris from a wound surface?
Hydrogen peroxide
When should you use hydrogen peroxide?
Very short time frame for appropriate use. INITIAL cleansing such as with “road rash.”
Can you change which dressing you use over time?
Yes, wounds change over time and so should the dressing
