Wound Debridement and Dressings Flashcards
What are the different kinds of debridement and cleansing?
Autolytic
Enzymatic
Mechanical (scrubbing, whirlpool, pulsed lavage, low frequency US)
Instrument (sharp, surgical, hydrosurgical)
Biological
What is SELECTIVE debridement?
Only nonviable tissue removed
What is NON-SELECTIVE debridement?
Viable and nonviable may be removed
What are factors to consider prior to debridement?
Overall condition of the patient
Etiology of the wound
Types of necrotic tissue present
Potential of wound to close due to local and systemic factors
Ability to achieve pain control during process
PT’s knowledge and skills
What is autolytic debridement?
Body’s endogenous enzymes loos and liquefy necrotic tissue
What are the advantages of autolytic debridement?
Least painful form
Can be used on all wound types (arterial wounds more difficult)
Minimal technical skill of PT required
What are the disadvantages of autolytic debridement?
Slower than other methods (usually taking weeks)
Requires multiple dressing changes
- Need to monitor fluid collection under the dressing
May not be appropriate for older patients with multiple comorbidities, impaired immune system, nutrition, and hydration deficits
What is the only absolute contraindication for autolytic debridement?
Infection
What is enzymatic debridement?
Uses topical meds designed to break down deviatalized collagen in the wound bed
Presently, collagenase Santyl is the only commercially available enzymatic debridement agent
Best applied daily
Cross-hatch dry and dense eschar
What are the advantages of enzymatic debridement?
Selectively targets and destroys devitalized collagen that anchors necrotic debris
Not associated with increased patient discomfort
No known effect on viable tissue
What are the disadvantages of enzymatic debridement?
Potential for skin maceration
Denudement of surrounding skin may occur
Can be deactivated (detergents, iodine, silver, mercury)
What is mechanical debridement?
Uses external forces or energy to dislodge and remove debris from wound surface
Can be selective or non-selective
What are the types of mechanical debridement?
Soft abrasion debridement
Hydrotherapy (whirlpool and pulsed lavage with suction)
Low frequency US
What is soft abrasion mechanical debridement?
Uses dry gauze or a cotton swab to gently lift and remove non-adherent debris and congealed exudate
May cause some pain (use topical anesthetic)
Can gently abrade wound edges to prevent epibole
What is wet-to-dry or wet-to-moist mechanical debridement?
DO NOT PERFORM WITH NON-SELECTIVE
Open weave gauze is wetted and placed in the wound so that it is in contact with all parts of the wound surface
Let gauze dry and adhere to the tissue which will come with it with removal
What are the disadvantages of wet-to-dry or wet-to-moist mechanical debridement?
Removes all types of tissue
Gauze doesn’t have to dry to cause damage
PAIN!!
Gauze as a packing material is often over-packed
Exposed bone, muscle, or tendon is likely to desiccate
Cowan et al (‘09) found what about wet-to-dry mechanical debridement?
This method is often inappropriately prescribed for wounds not needing debridement in more than 78% of wounds for which they were ordered
What is the hydrotherapy method of mechanical debridement?
DO NOT USE A WHIRLPOOL
This method facilitates cleansing by immersing the patient or body part in a tub that uses a motor to circulate and agitate water and loosen debris
What are the risks of hydrotherapy?
INFECTION!!
Biofilm growth in the machine
Cross-contamination
Which wounds may be inappropriate in general for hydrotherapy?
Infected wounds
Venous wounds (wet and dependent position)
Diabetic (can’t feel the water temperature; maceration–allows for bacteria to get in)
What is involved with HYDROSURGICAL instrument debridement?
Precisely removes non-viable tissue using a high energy water stream
What is the benefit of hydrosurgical instrument debridement?
Very little damage done to underlying healthy tissue
What is biological debridement?
Maggot debridement therapy (MDT)
Documented use since the 16th century
3 proposed actions:
- Debridement of necrotic tissue
- Antimicrobial activity
- Facilitation of wound healing
What are the factors that influence dressing selection?
Bacterial profile
Wound characteristics
- Dry
- Moist
- Heavy exudate
- Malododorous
- Painful
- Difficult to dress
- Bleeds easily
Wound type
- Depth
- Etiology/cause
Stage of healing
Tissue types:
- Necrotic
- Slough
- Granulating
- Epithelialization
What do you want a dressing to do?
Rehydrate
Absorb exudate
De-slough
Reduce bacterial contamination
Promote granulation
Promote a moist/dry wound bed
What are characteristics of an ideal wound dressing?
Provides moist wound environment
Manages exudate
Facilitates autolytic debridement
Antimicrobial if needed
Minimizes pain
Prevents contamination from environment
Insulates and maintains optimal temperature
Easily applied and removed
Available and cost-effective
What is the goal of primary dressing?
Prevent adherence
Correct absorptive capacity
- Moisture additive or moisture retentive as needed
What is the role and function of secondary dressing?
Placed over the primary dressing
Absorb exudate
Provide cushioning to protect the wound
Possibly act as occlusive barrier to prevent drying or prevent bacteria from entering the wound
What are skin protectants?
Also called moisture barriers
Wipes, foam applicators, and sprays used to protect skin from mechanical injury caused by tapes and adhesives
Help prevent maceration and tearing of skin
With or without alcohol
- Consideration for inflamed periwound tissue
What are contact layers?
Barrier between wound surface and a secondary dressing
Can be coated with silicone, oil emulsion, or petrolatum
Usually removed with each dressing change, but can be left in place with heavily draining wounds
Not recommended for dry wounds, third degree burns or other wounds that need contact moisture
What are the advantages of contact layers?
Protects a wound from trauma
Allows exudate to pass through
Can be cut to fit the wound or allowed to overlap with adjacent skin
Great to use with NPWT
What are transparent films?
May be applied to heels preventatively to reduce friction and shear
Self-adherent
Allows wound to be observed
Do NOT use on draining or infected wounds–does not absorb exudate
Waterproof, but allows for water vapor to evaporate and oxygen is able to penetrate
Often used as a secondary dressing and with NPMT devices
What are hydrogels?
Comes in sheet and gel form
High water content facilitates debridement by rehydration–autolytic debridement
What are the indications for hydrogels?
Burns
Hard to heal wounds
Dry wounds that need moisture
What are some contraindications to using hydrogels
Heavily exuding wounds
Maceration of the peri-wound area
Infected wounds
What are hydrocolloids good for?
Wounds with minimal to moderate drainage
What are the advantages of hydrocolloids?
Self-adherent
Provides cushioning over bony prominences
Maintains a moist wound environment
Facilitates autolytic debridement
Effective under compression wraps
Come in various shapes, sizes, and thicknesses
What are the disadvantages of hydrocolloids?
Difficult to remove from the fragile skin
May leak or leave a residue on the skin
Require a different primary dressing to fill in spaces
Not effective on wounds with dry eschar
Do NOT use on infected wounds
What are the characteristics of foams?
Wicks away fluid from wound
Adhesive or non-adhesive
Various shapes and sizes
Extend at least 1 inch onto peri-wound skin
What are the uses of foam?
Moderate to heavy exudate
With/without granular bed
Can be used on infected wounds, but must be changed daily
What are the precautions associated with foams?
3rd degree burns
Little to no exudate
Not comfortable
What are alginates?
Dressings with calcium and sodium fibers made from seaweed spun into a rope or in sheet form
Used to absorb moderate to heavy drainage
Calcium fibers react with exudate or blood to form a gel–keeps the wound moist
May be used on infected wounds or for filling deep cavity wounds–great for cavities
May be used as a hemostatic dressing
Requires a secondary dressing to cover the wound
What are the characteristics of hydrofibers?
Similar to calcium alginate dressings
Used as a primary dressing in contact with the wound
Converted into gel when in contact with moisture
If infused with silver, it is antimicrobial
Can be worn for several days
What are the uses for hydrofibers?
ABSORBS EXUDATE!!
Partial thickness burns
Diabetic foot/leg ulcers
Pressure ulcers
Traumatic wounds
What are the precautions associated with hydrofibers?
Not compatible with oil-based products (petroleum jelly)
What are some common Collagens and what are their characteristics?
Promogran, Puracol, Fibracol
Sheets, ropes, gel, pad
Collagen promotes wound healing
Moderate absorption of exudate
Non-adherent
What are some uses for collagens?
In wounds without necrotic tissue
What are some precautions associated with collagens?
Not for 3rd degree burns, dry wounds, or wounds with eschar
May not be appropriate for patients with sensitivity or cultural restrictions relative to the use of bovine or porcine products
What are the characteristics of gauze?
Cotton or synthetic
Many sizes, shapes, forms (rolls, pads, strips)
Cheap
Plain or impregnated (Petrolatum is gauze impregnated with petroleum)
What are the uses for gauze?
Everything–scrubbing, prepping, wiping, protection, absorption, and packing
Saline soaked gauze–keep wound moist as primary dressing
Loose packing of deep wounds (primary dressing for packing)
Can be used as a secondary dressing to absorb exudate
What are some precautions associated with gauze?
Wet to dry debridement when gauze dries in the wound
What are the characteristics of Petrolatum?
Non-adherent primary dressing
Vaseline on gauze
What are the uses for Petrolatum?
Primary layer used to maintain moisture within wound
Inhibit loss of body fluids
Protects wound from contamination
What are the characteristics of Telfa pads?
Non-adherent primary dressing
Mild absorption of exudate
What are some uses of Telfa pads?
Dry sutured wounds
Superficial cuts and abrasions
Lightly exuding wounds
What are the precautions associated with Telfa pads?
Careful using on wounds that produce heavy, viscous exudate (leg ulcers)
May trap exudate and cause maceration or inflammation of periwound skin as telfa pads are not very effective at absorbing fluid
What is bioburden?
Refers to the effect of organisms within a wound bed that influence wound healing
All chronic wounds have some level of bioburden
- Bacteria does not = infection
Range of bacterial influence:
- Contamination
- Colonization
- Critical colonization
- Infection
What is contamination?
Presence of bacteria on wound surface
Bacteria are NOT multiplying
NO host response
- No inflammatory response
What is colonization?
Presence of bacteria that have attached superficially to the wound
NO invasion of healthy tissue
Bacteria ARE multiplying
NO host response
- No inflammatory response
- No signs and symptoms
What is critical colonization?
Presence of bacteria that have attached superficially to the wound
Bacteria ARE multiplying
Invasion of healthy tissue = local tissue damage
Presence of 1 or 2 signs of infection
What is infection?
Movement of replicating bacterial from superficial to deep tissues
Signs and symptoms:
- Local: pain, redness, swelling, heat, odor, purulent drainage
- Systemic: elevated WBC, fever, confusion (older adults), red streaks from the wound
Bacteria has overwhelmed the host’s immune response
Diagnosed primarily by clinical observation and confirmed with lab tests
What is the contamination-infection continuum?
See ppt (Part 2, slide 7)
What are the topical antimicrobial dressings?
Silver
Honey
Methelyne blue
What are some characteristics of silver?
Most popular for reduction of bioburden
- Release silver into the wound in the presence of exudate
- Active against MRSA, Staph A., pseudomonas, VRE
Found in:
- Hydrogels–gel and sheet
- Alginates
- Hydrofibers
- Foams
- Silicones
- Contact layers
- Wound powders
- Ointments
- NPWT foams
- Irrigation silver nitrate solutions
Should not be used with other antimicrobials
Should only be used for short periods of time (reduce the risk of resistance)
What are some characteristics of honey?
Acidic pH (3.5-4) inhibits pathogens - Promotes autolytic debridement and moist wound healing
MEDICAL grade
Found in:
- Gels
- Sheets
- Ointments
For use on infected or highly contaminated wounds
Do not use if:
- Allergic to bees
- Hypersensitivity reactions
Stop when clinical signs of infection are no longer apparent
Conflicting evidence
What are some characteristics of Methylene Blue?
Lack of conclusive and quality research regarding effectiveness
Removes exudate from the wound bed and creates singlet oxygen (O) and free radicals which impacts the plasma membrane and causes bacteriolysis
Clinically…it has been shown to:
- Decrease inflammation and pain
- Improves granulation
- Reduce wound edge epibole
- Reduce hypergranulation
What are the steps to application of Methylene Blue?
See ppt (Part 2, slides 13 & 14)
