Wound Bed Preparation Flashcards
Purposes for Debridement
Decreases bacterial concentration within the wound bed and risk of infection
Increase effectiveness of topical antimicrobials
Shorten inflammatory phase
Decrease odor
Eliminate barrier to wound healing
Improve bactericidal activity of leukocytes
Decrease energy needed for wound healing
General Indications for Debridement
Removal of necrotic tissue, foreign material, debris, senescent cells
Removal of biofilm
Correction of wound edges including callous, hyperkeratosis, non viable borders, epibole
Removal of residual topical agent
Red–yellow–black system
Black eschar, full-thickness
Yellow draining wound with slough
Red granular wound
Wounds may present with combination
Slough- yellow fibrin debris :
moderate to high water content. Lies on top of wound and is generally moderately to lightly adhered
Eschar- brown to black necrotic tissue
May be soft or hard. Occurs with full thickness tissue destruction
Biofilm
Polymicrobial
Reach bacterial levels of critical colonization
Present in 60% of chronic wounds
Invisible, wound bed appear pink/red and viable
General Contraindications
for Debridement
Avoid trauma to viable tissue
Do not debride heel ulcers with eschar if they do not have edema, erythema, fluctuance, drainage
Wounds that require surgical debridement
Electrical burns prior to physician assessment
General Considerations
for Debridement
Characteristics of wound
Status of patient
Existing practice acts
Clinician’s knowledge and skill level
Methods of Debridement
Autolytic Enzymatic Mechanical Biological Sharp Surgical
Selective Debridement
Sharp
Autolytic
Enzymatic
Nonselective Debridement
Mechanical
Surgical
What is autolytic debridement?
Body’s own enzymes
What wounds would use autolytic debridement?
Stage III or IV wounds with light to moderate drainage
How is autolytic debridement performed?
Performed by occlusive or semi-occlusive dressings (hydrocolloids, hydrogels, or films) which keep wound fluid in contact with necrotic tissue
What tissue is targeted with autolytic debridement?
Selective, only necrotic tissue is liquefied
Painless
Slower than surgical debridement.
May macerate surrounding tissue.
Indications of autolytic debridement:
All wounds with necrotic tissue
Patients who cannot tolerate other forms of debridement
Commonly used in home or long-term care settings
Contraindications of autolytic debridement:
Infected or deep cavity wounds
Wounds that require sharp or surgical debridement
Autolytic Debridement:
Procedure
Crosshatch eschar
Moisture-retentive dressings
Protect periwound
Moisture-retentive dressings
~2 cm larger than wound
Keep on for 72–96 hours
What is enzymatic debridement?
Form of selective debridement
Requires physician’s prescription
Selectively digests protein, collagen, and fibrin.
Which wounds would use enzymatic debridement?
Wounds with a large amount of necrotic debris or eschar formation
Less painful for patients unable to tolerate sharp debridement
What enzyme is used for enzymatic debridement?
Collagenase - only enzyme currently FDA approve
Drawbacks to enzymatic debridement?
Expensive, requires prescription, requires frequent re-application and dressing changes
May cause inflammation or discomfort
Slower process than sharp debridement
Can be applied by caregiver not skilled in sharp debridement
Enzymatic Debridement Indications
Infected and uninfected wounds with necrotic tissue
Appropriate if cannot tolerate sharp debridement
Appropriate in-home or long-term care
Enzymatic Debridement Contraindications:
Wounds with exposed deep tissues Facial burns Calluses Wounds free of necrotic tissue Exogenous enzymes should not be applied to wounds being autolytically debrided
Enzymatic Debridement:
Procedure
Follow manufacturer’s guidelines Physician’s prescription Crosshatch eschar Moist environment Observe for infection Topical antimicrobial therapy as needed Collagenase is deactivated by silver and iodine ions Apply 2mm thick Must be applied daily Must have a moist environment
Mechanical Debridement
Use of force to remove devitalized tissue, foreign material, and debris
Nonselective
Kinds of mechanical debridement:
wet-to-dry dressings scrubbing wound cleansing wound irrigation pulsatile lavage whirlpool hydrogen peroxide
Benefits of mechanical debridement:
Wounds with moderate amount of necrotic debris
Low cost
Drawbacks to mechanical debridement:
May traumatize healthy tissue
Painful
Wet-to-Dry Dressings
Apply saline-moistened gauze Allow to dry Tear away dressing Prior standard dressing Now many better options Only indicated for wounds with 100% devitalized wound bed
Scrubbing:
High-porosity sponge, brush, or gauze
Water or saline
Contraindicated for granulating wounds
Best used for highly contaminated superficial wounds/burns
Temperatures for whirpool non-thermal
80-90
Temperatures for whirpool neutral
92-96
Temperatures for whirpool thermal
96-104
Whirpool
Removes dirt and foreign contaminants
Removes toxic residuals from topical agents
Softens & rehydrates necrotic tissue
Removes toxic residuals from topical agents
Drawbacks to whirpool
Additives may be cytotoxic (proper concentration?)
Force from jets may be traumatic (no evidence)
Nonspecific mechanical debridement
Appropriate for non-venous wounds with thick exudate and slough or infected wounds/abscesses
Pulsative Lavage
Removes dirt and foreign contaminants, Softens necrotic tissue Removes toxic residuals from topical agents Nonspecific mechanical debridement 4-15 PSI
Contraindications to pulsative lavage:
Contraindicated over granulation tissue
Caution/contraindication if on blood thinners
Jet-ox
Mist of saline delivered by pressurized oxygen
Gentle to wound
Rehydrates necrotic tissue and gently debrides
US Mist
Mist created by US
Rehydrates necrotic tissue and gently debrides
May provide benefits of US for wound healing as well as debride
Possible aerosolization of contaminants
Low Frequency Contact US
Utilizes currete with saline spray as coupling medium
Low frequency US is powerful enough to liquefy adipose tissue and disrupt biofilm
New units include suction
Biological Debridement:
magoot therapy
FDA-approved live medical device for debridement
Seldom used in the U.S.
How maggot therapy works:
Larvae release enzymes that degrade necrotic tissue
Larvae ingests necrotic tissue and bacteria
Larvae are unaffected by antibiotics
Benefits of maggot therapy:
Faster than autolytic and enzymatic debridement
May decrease odor and exudate
May increase granulation and epithelialization
Sharp
Selective, necrotic tissue only
Use of forceps, scissors, or scalpel
Fastest, most aggressive form of debridement
May also be used to correct improperly healing edges, epiboly
Indications of sharp debridement:
Large amount of necrosis, callus, advancing cellulitis, sepsis, eschar
May be used on wounds with any amount of necrotic tissue
Chronic wounds
Contraindications of sharp debridement:
When area cannot be adequately visualized
Material to be debrided is unidentified
Lack of clinician competency
Infected ischemic ulcers with low ABIs
Precautions for sharp debridement:
immunosuppressed, thrombocytopenic, or on anticoagulants
Wound closure is not consistent with POC
Hypergranular tissue
Sharp Debridement:
Termination
Lack of pain control
Patient tolerance to technique
Extensive bleeding
Sharp Debridement:
Procedure
Scalpel and scissors parallel to surface
Debride in layers
Rinse wound with saline and reassess
Surgical Debridement
Use of scalpels, scissors, or lasers in sterile environment
Selective
May be performed in OR or at bedside
Typically large amount of necrotic or non-viable tissue or purulence
May involve removal of viable tissue
Often performed due to active infection
Drawbacks of surgical debridement:
Painful
Expensive
Performed by physician or podiatrist
Allows for extensive exploration of wound bed and debridement of deeper structures
Indications for surgical debridement:
Ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining
Necrotic tissue near vital organs/structures
Contraindications for surgical debridement:
Patients who are unlikely to survive procedure
Patients with palliative care plans
