Integument Debridement & Management Flashcards
Removal of necrotic tissue, foreign material, debris and decrease risk of infection and promote wound healing
Purpose:
● 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
● Decrease wound odor
debridement indicated:
● necrotic tissue
● foreign material
● debris
● residual topical agents
● blisters
● callus
debridement contraindications:
● granular tissue
● viable tissue
● urgent need for surgical debridement (gangrene, osteomyelitis)
● electrical burns
● grade IV pressure ulcers
red wound bed
pale pink to beefy red, granulation tissue
treatment goals:
● protect wound
● maintain warm, moist environment
● protect periwound
yellow wound bed
moist, yellow slough
treatment goals:
● debride necrotic tissue
● absorb drainage
● protect periwound
black wound bed
thick, black, adherent eschar
treatment goals:
● debride necrotic tissue
types of selective debridement:
Sharp
Autolytic
Enzymatic (Chemical)
Biological
Sharp overview:
● Serial Instrumental Debridement
○ Forceps, scissors to remove loosely adherent necrotic tissue
○ prior tissue preparation
○ (irrigation, whirlpool, suction)
● Selective Sharp Debridement
○ Scissors/scalpel to cut along the border of viable and nonviable issue
○ No tissue preparation
Sharp process:
● Fast and most aggressive
● Hold the scalpel & scissors parallel to the wound surface and debride in layers to keep from incising on healthy tissues
● Use forceps to apply gentle traction to the devitalized tissue
Sharp used for:
● Large amount of necrosis
● Callus
● Cellulitis or sepsis
● Thick, adherent eschar
Sharp poor for:
● Extensive tunneling/undermining (PT can’t see where to debride)
● Unidentified material to debride
● Uninfected ischemic ulcers (Ischemic ulcers less likely to heal without adequate blood flow)
● Low ABI
● Areas of hypergranulation tissue
Autolytic overview:
● Most conservative, least painful but slow process
● Allowing the body to produce enzymes to digest necrotic material
Autolytic process:
● Warm and moist wound
● Dressing to seal wound (hydrogel, foam, hydrocolloid)
● Wound releases endogenous enzymes
○ Liquefied necrotic tissue
○ Inflammatory & proliferative phase accelerated
Autolytic used for:
● Wound should present with necrotic tissue
● Pt cannot tolerate other forms of debridement
● Frequently used in LTC, home care settings
● Palliative treatment
Autolytic poor for:
● Infected wounds
● Deep cavity wounds
● When sharp or surgical debridement is mandated
● Gangrene, necrotic tendon…
Enzymatic (Chemical) overview:
● Exogenous enzymes to remove devitalized tissue
● Physician prescription required
● Less skill but long process
Enzymatic (Chemical) used for:
● Necrotic tissue (w/ or w/o infection)
● Autolytic doesn’t work
● Benefit from exogenously supplied
enzymes
● Combine antimicrobial
therapy if infection present
Enzymatic (Chemical) poor for:
● Exposed deep tissues, Ligament, tendon, capsule, blood vessels, nerves, or bones
Biological overview:
Maggot debridement
Biological process:
● Sterile maggots placed for ~ 3 days
● Maggots ingest/ destroy necrotic tissue/bacteria by releasing enzymes
● Viable tissue is spared
Biological used for:
● Necrotic tissue
Nonselective Debridement:
Removal of non-specific areas of devitalized tissue
Mechanical
Surgical
Mechanical: Wet-to-dry dressings process:
- Apply moist gauze
- Cover with dry gauze
- Gauze adheres to wound
bed - Then tear away from
wound bed
○ May remove both good
and bad tissue
Mechanical: Wet-to-dry dressings used for:
● ONLY if entire wound bed is necrotic
