Wound bed cleansing and debridement Flashcards
What are the components of wound bed prep
- Tissue
- infection: reduction of infection/inflammation
- moisture management
-
Edges: prevention of edge rolling
TIME - Debridement
- Infection control
- Moisture regulation
-
Edges mirgation of wound edges
dime
What do you do each visit for wound cleasning
ie: what is the goal of wound cleansing
- Goal: clean without traumatizing wound bed or driving bacteria into the wound
- removes debris, bacteria dressing residue
- delivers cleasning solution to the wound by mechanical force
- aides in separation of necrotic tissue from health wound tissue
- cleanse wound bed and peri wound area
Must chose cleasning solution and method of delivery
Types of cleasning solutions
- isotonic normal saline
- commercial solutions (ex dakin solution, ascetic acid, povidone-iodine)
what is
Isotonic Normal saline
- nontoxic inexpensive physiologic
- no preservatives lasts 24-48 hours after opening
- works well with normal, clean wound
cleansing solutions
Commercial solutions
- contain surfactants to help loosen matter from wound surface
- skin cleansers that are designed for external use are not appropriate wound cleansers (kills good and bad)
types of cleasning methods
- soaking
- whirlpool
- scrubbing
- irrigation
types of cleasning methods
soaking
what does it do?
- removes cross contaminants and lossen necrotic tissue
- eases the separation of necrotic tissue and dressing debris from healthy tissue
- significant injuries (not long term)
`
types of cleasning methods
Whirlpool
- not recommended
- cleasning, non-selective debridement and thermal effects
types of cleasning methods
scrubbing
- gauze/sponge with mechanical force to remove debris
- can cause mircoabrasions in wound with healing delay
types of cleasning methods
irrigation
- lavage-therapeutic washing
- low pressure < 4psi w/ bulb syringe or pouring solution
- high pressure 4-15 psi commercial devices a syringe, pulsed lavage
what is debridement
and why is it effective?
- remove nectoric tissue
- decrease bacterial concentration/bioburden
- increases effectiveness of topical antimicrobials
- improve bactericidal activity of leukocytes
- decreases energy required by body for healing
- decreases wound odor
- remove callous, rolled edges
what does stable heel ulcer look like
- no signs of infection
- edges begin to separate
- trim away edges as needed
- may fully heal slowly
methods of debridement
- selective: only nonviable tissue is removed (hope to use this)
- nonselective: both viable and nonviable tissue may be removed
what are the types of debridgement
- autolytic
- enzymatic
- mechanical
- instrument
- biotherapy
types of ddebridment
autolytic
- allows bodies own tissue to break down nonviable tissue
- process of body’s endogenous enzymes loosen and liquify necrotic tissue in wound bed
types of ddebridment
enzymatic
- thin layer on top to breakdown non-vaible
- pharmaceutical enzymes breakdown devitalized collagen in wound bed
- collagenase
types of debridment
mechanical
- external forces or energy directed to wound surfaces to dislodge/remove debris/bacteria/necrotic burden
- soft abrasive; hydrotherapy; wet-dry; low frequency contact US
- this can be selective or nonselective
types of ddebridment
instrument
- use of instruments to execise and cut away necrotic tissue
- scalpels, forceps, curettes, surgical
`
types of ddebridment
Biotherapy
- maggot debridement
Low frequency contact US
- utilizes the process of US waves to improve cellular stimulation to kill bacteria and create cavitation
mechanical debridement
what is
pulsatile lavage with suction
- irrigation combined with sution
- provides cleansing and debridement
- battery powered with selection of tips
- pulsed irrigation provides positive pressure (4-6 psi initially/recommended range of 4-15 psi)
- suction provides negative pressure to remove irrigant and debris
60-100mmHg of continuous suction
What are the benefits of PLWS
pulsatile lavage with suction
- customizable settings: gentle for wound cleansing, stronger for irrigation and debridement
- reduces bacterial counts and infection: high pressure irrigation in acute contaminated wounds decreases contaminants and incidence of infection
- promotes production of granulation tissue
pulsatile lavage with suction infection control guidelines
- treatment patient in private room
- cover exposed supplies
- cover exposed tubes, ports, and other wounds
- consider masking patient
- no family/vistors in room
- observe standard precautions
- PPE
- proper disposal of waste and suction canister
- do no reuse single-use items
- after treatment disinfect all surfaces touched
what are the effects of hydrotherapy with wound treatment
- consists of immersion in a tub or water with agitation
- thermal effects
- neuronal effects
- cellular
- cleasning
- debridement: turbine action, loosens noviable tissue, may damage granulation tissue
what are the risks with whirlpool in wound management
- dependent position = increase edema
- tissue damage = potential trauma from mechanical forces
- CHF, venous insufficiency, Beta blockers, lightheaded/dizzy.
- risk of spread of infection
- skin maceration
- overheating insensate tissues
what does enzymatic (chemical) debridement do
- using concentrated, commercially prepared chemical on the surface of nonviable tissue
- digests the devitalized tissue and or loosens the bonds between noviable and viable
- collagenase (santyl) = physicians orders is required
- can be used alone or with other modalities like sharp debridement
bromelain- new not mainstream/approaved by FDA
Explain the process of enzymatic debridement and how it can be used with otherr debridement types such as with sharp debridement
- thin 2mm layer of ointment applied directly to tissue and covered with appropriate dressing
- enzyme activated by moisture, so secondary dressing must maintain moisture
- not meant for hard dry eschar
- must cross hatch the eschar to allow penetration or use on the perimeter of the wound
proccess of autolyic debridement
Describe what occurs?
- moisture retentive dressing applied to a cleansed wound (transparent films, hydrogels, hydrocolloid dressing)
- moisture promotes rehydration of dead tissue and allows enzymes to digest necrotic tissue
- facilitates autolysis by cross hatching eschar
- slower than sharp debridement
- painless
- selective
- effective in combo with other methods
Autolytic dressing choices
- transparent films
- hydrocolloid
- hydrogels
- must monitor fluid closely and prevent prolonged exposure to intact skin
- contraindicicated in infected wounds
what happens with sharp debridment
- aka instrumental debridement
- use of tools to remove necrotic tissue, scalpel, forceps, curette, scissors
- most rapid form of debridement
- preferred method for necrotic tissue
- can be used in conjunction with enzymatic debridment
do not remove stable heel eschar
advantages of sharp debridement
- most rapid form of debirdement
- can be highly effective in wound management, particularly in diabetic foot ulcer and venous leg ulcers
- can be performed by MD’s nurses and PTs
disadvantages of sharp debridement
- requires high level of experience
- reimbursement may be denied
- may be painful for patient (may need anesthesia)
- potential for complications
- blood loss
- infection
- injury to underlying structures
what is biosurgical debridement
- MDT: maggot debridement therapy; the application of maggots to remove non-viable tissue
- approved by FDA in 2004 as live medical device for debridement of necrotic tissues
What are some things to consider before debriding
- overal condition of the patient and their ability to achieve and sustain a closed wound
- inclusion of the patient’s and family’s individualized goals for care
- the patient’s ability to adhere to the POC
- etiology of the wound
- Types of necrotic tissue
- potential of the wound to close and heal due to local factors
- potential of the wound to close and heal due to systemic factors
- ability to achieve adequate pain control during debridement
- clinician’s knowledge, skills and expertise
- available resources to support wound care
what are some reasons to refer someone based on a wound
- dry gangrene or dry ischemic wounds (vascular consult)
- increased temperature or signs of systemic disease (Sepsis)
- extensively underminded wounds
- failure of wound to progress (4 weeks is acceptable for improvement)
- cellulitis or gross purulence/infection
- exposed bone, tendon, prosthetic devices or vital structures
- abscessed area or extensive undermining
What are some factors that impede wound healing
- biofilm
- infection: bacterial or fungal
what is biofilm
- an assemblage of surface-assoicated microbial cells that become enclosed in an extracellular polymeric substances (EPS) matrix
- a bacterial colony encased in a polysaccharide matrix and attached to the wound surface
What does biofilm mean in terms of healing
what characteristics diminish healing
- aherent to wound bed
- provides an environment for bacteria to live and replicate
- not easily removed
- resembles a layer of slough or can be invisible
- MUST be removed for healing to occur
Managing bioburden
- all wounds have some bacteria
- want to create a good wound environment so that the bacteria does not replicate and lead to infection
Contamination
presence of non-replicating bacteria, no effect on healing
colonization
presense of replicating bacteria
no effect on healing
critical colonization
- replicating bacteria with amounts to visibly affect healing
infection
and how does this delay heling
- bacteria 10^5
delays healing by:
- extending inflammatory response
- delays collagen
- slows epithelialization
- causes more injury to tissues
sepsis
- replicating bacteria producing whole body inflammatory state
what happens with suspect an infection
medically?
- local vs systemic?
- determine type
- determine amount
- stain for +/-
clinical signs
localized infection
- new/increased pain
- delayed healing
- edema around wound
- bleeding/friable tissue
- malordor
- discolored wound bed
- increased exudate/purulence
- induration
clinical signs
critical colonization
- static wound not responding to tx
- new/changin pain
- thick slough not responding to debridement
- slough return rapidly
- persistant malodor
wound cultures
- lab test
- microorganisms from an infected wound, are grown in the lab and identified
- must capture the bacteria in the wound not on the surface
- tissue biopsy, need aspiration, curettage, swab technique
What are some common infectious agents
1. aerobes
2. anaerobes
3. fungus
- aerobes
- steptococcus
- staphylococcus
- MRSA
- pseudomonas
2. anaerobes - bacteriodes
- fusobacterium
3. fungus
candida
How to prevent infection
Sterile techniques:
- all instruments and materials are sterile
- providers wear sterile gloves, caps, masks, and gowns
- sterile technique used
Clean technique:
- involves procedures that reduce the number of pathogens and decreases the transfer of pathogens
topical antimicrobials vs system antimicrobials
- topical agents: limit colonization without continual reinfection from superficial bacteria
- system antimicrobials: often superior to topical agents in treating invasive infections
- some antimicrobials can be damaging to health tissue
what are some examples of antimicrobials
- bacitracin
- mupiricin
- gentamycin
- silver sulfadiazine
- honey
Antispetics
- chemical compounds that destory or inhibit growth of micoorganisms, diluted to render them safe on living tissues
- also used to disinfect instruments and materials
- decrease bacterial load on intact skin
- available as hand scrubs, cleansers or irrigants
- types: povidone iodine, cadexomer iodine, acetic acid, hydrogen peroxide, hypochlorites
antifungal agents
- 50 species of fungi that are pathogenin to humans
- can be fungicidal or fungistatic (inhibit growth)
- ex: miconazole nitrate, nystatin, clotrimazole, flucanazole
