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
Mechanical: Wet-to-dry dressings poor for:
● Dry wound
○ Delays granulation tissue forming
○ Dryness can damage tendons, fascia, and joint capsules
Mechanical: Scrubbing process:
● Use of sponge, brush, or gauze to debride wound
Mechanical: Scrubbing used for:
● Benefits? Cheap, larger area, fast and clean
Mechanical: Scrubbing poor for:
● Risks? Take the good material too
Mechanical: wound cleansing process:
● Use of commercial solution with force to remove lightly adhered necrotic tissue
Mechanical: wound cleansing used for:
● Appropriate for superficial wounds
Mechanical: wound cleansing poor for:
● Chronic/deep wounds
● Can be cytotoxic and
delay wound healing ○ Not FDA regulated
Surgical:
● Performed by physician or podiatrist
● Use of surgical tools in sterile environment
Management:
Irrigation
Whirlpool
Pulsed Lavage with Concurrent Suction
E-Stim
Ultrasound
Holistic
Irrigation overview:
● Use of Saline
Irrigation process:
Removes:
● Loose cellular debris
● Surface bacteria
● Wound exudate
● Dressing residue
Irrigation used for:
● Only option for well healing granular tissue
Irrigation poor for:
● Profuse bleeding from wound
Whirlpool overview:
● NOT USED IN CLINIC ANYMORE
Whirlpool process:
● Area of wound is submerged in pool with circulating water
Whirlpool used for:
● Burn wounds
● Reduce bacterial load
● Non-draining wounds to help rehydrate
● Soften thick eschar tissue
● Gently remove loosely adherent necrotic tissue
Whirlpool poor for:
● Venous insufficiency or lymphatic ulcers
○ Sensation, Low BF and swelling
● Bowel and Bladder incontinence
● Cross contamination between patients
● Non-selective
● Wound maceration risk
Pulsed Lavage with Concurrent Suction process:
● Handheld device using pressurized saline
Pulsed Lavage with Concurrent Suction used for:
● Used for most wounds
○ Tunneling & undermining wounds okay
Pulsed Lavage with Concurrent Suction poor for:
● Deep wounds with vital structures visible
E-Stim overview:
Wound healing facilitation:
1. Restoring the current of
injury
- Causes Galvanotaxis
- Stimulate Cells
- Increases blood flow
- Increases bactericidal
abilities - Reduces edema
- Facilitates Debridement
E-Stim process:
● Technique
○ Direct Contact
○ Immersion technique
○ Periwound technique
E-Stim used for:
● Adjunct to wound healing
● Canbeusedasaco treatment option for all wounds
E-Stim poor for:
● Used in chronic non healing wounds or for patients at risk of delayed wound healing
● Wounds with osteomyelitis
Ultrasound overview:
● Can enhance all 3 phases of wound healing
● Improves scar pliability
● Enhances wound contractility
Ultrasound process:
● result from changes in cell membrane permeability
Ultrasound used for:
● Adjunct for chronic wounds
Ultrasound poor for:
● General US precautions
● Untreated osteomyelitis
● AI
● DVT
Holistic overview:
Nutrition, Water (fluid environment), Protein (restructuring of cells), Fats (fuel the healing process), Vitamins/Minerals
