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Wound 2
Acute Care Debridement Lecture
| Question | Answer |
|---|---|
| Purposes of Debridement | Remove necrotic & infected tissues; Enhance wound healing; Decrease risk of infection |
| Methods of Debridement | Selective, Surgical, Sharp, Non-selective, Gauze/swab, Wet-to-dry, Vacuum-Assisted Closure (VAC), Hydrotherapy |
| Can PT's perform surgical debridement? | No |
| Can sharp debridement be performed by PT's or PTA's? | Only PT's according to APTA position paper |
| What is sharp debridement? | Removal of non-viable tissue with sterile instruments |
| Clinical Indications for Aggressive Debridement Methods | Majority of wound covered with necrotic tissue; Goal of therapy is quick removal of necrotic tissue; Wound continues to improve with current therapy |
| Clinical Indications for Less Aggressive Debridement Methods | When aggressive debridement is no longer indicated; Majority of wound is clean & granulating; No threat to pt's health- don't suspect they will become septic |
| Selecting the Appropriate Method | Wound characteristics (color, adherence, etc) Degree of desired aggressiveness (might be based on pt) Time available for debridement Skill of clinician Care setting |
| Bacterial Burden | Contamination (infection continuum; presence of "bug"; no such thing as fully sterile) Colonized Critically colonized (pt where adverse rxns are caused) Infection (does level of bacteria lead to infection?) |
| Classic s/sx of infection- Acute wound infection or severe chronic wound infection | Advancing erythema; Fever; Warmth; Edema/swelling; Pain; Purulence |
| 2ndary s/sx of infection: Critically colonized, increased bacterial burden, local wound infection | Delayed healing; Change in color of wound bed; Friable granulation tissue (breaks off & bleeds) Absent/abnormal granulation tissue Increased abnormal drainage Increased serious damage Increased pain at wound site |
| Sharps Debridement | Used to clean dead & contaminated material; Aid in healing; Increase tissue ability to resist infection; Decrease inflammation; Tissue sample for testing & dx (only if you think area is infected) |
| Why would sharps debridement be performed? | Remove tissue contaminated by bacteria, foreign tissue, dead cells, or a crust; Create a neat wound edge to decrease scarring, Aid in healing very severe burns or pressure sores (decubitus ulcers) |
| Sharp Debridement Precautions | Need perfusion in wound/periwound tissue; Be careful if pt takes anti-coagulant; Penetrating fascia- this allows bacteria into underlying structures; Know anatomy to avoid unintended destruction/damage to tissue; Don't want any/much bleeding if possib |
| Sharp Debridement Contraindications | Poor perfusion of eschar when arterial insufficiency; Dry eschar over bone/tendon unless evidence of infection; Dry gangrene- debriding spreads infection; Pts with impaired clotting; Wounds w/ undermining/tunneling b/c can't see wound base |
| Maggot Therapy | Use sterile fly maggots to break down/ingest infected/necrotic tissue Maggots don't damage healthy tissue (they only eat non-viable tissue) Bacteria in wound is eliminated, reducing odor & allowing faster wound healing |
| Mechanical Debridement | Methods include whirlpool baths, use of syringe & catheter, or wet to dry dressings to remove dead/infected tissue |
| Indications for Mechanical Debridement (Gauze/Swab) | Non-adherent, moist necrotic tissue |
| Contraindications for Mechanical Debridement (Gauze/Swab) | Adherent, dry necrotic tissue that isn't easily removed (will tear off viable tissue) |
| Precautions, Disadvantages, & Methods of Gauze/Swab Mechanical Debridement | P: Anti-coagulant therapy D: Painful, inefficient, may destroy granulation tissue M: Use gauze sponge/calcium alginate-tipped swab, rub periwound necrotic tissue away from wound bed |
| Indications/Contraindications Wet to Dry Mechanical Debridement | I: Only on necrotic tissue with no visible granulation C: Presence of granulation tissue (would be destroyed) |
| Precautions, Disadvantages, Methods Wet to Dry Mechanical Debridement | P: Anti-coagulant therapy D: Painful, May destroy granulation tissue M: Apply wet (saline) gauze on necrotic tissue, allow gauze to dry & remove when dry, apply moisture to dressing before removal to minimize pain & damage to granulation tissue |
| Indications for Mechanical Debridement (Whirlpool) | Loosely adherent necrotic tissue Exudate Debris |
| Contraindications for Mechanical Debridement (Whirlpool) | CV/Pulmonary compromise (esp. with submersion); Renal failure; Acute phlebitis; Pts with temp 101.9+ Evidence of dry gangrene Non-necrotic neuropathic foot Periwound maceration Extremity edema B/B incontinence with full-body WP |
| Whirlpool Precautions | Venous insufficiency shouldn't be in dependent position in warm water; Weight of pt- when exceed weight tolerance of lift, then it's contraindicated |
| Whirlpool Disadvantages | Inability to control force of jts; Labor intensive procedure; May cause maceration |
| Whirlpool Methods | Disinfected whirlpool; No additives to water; Follow traditional whirlpool procedures |
| Mechanical Debridement: Pulsatile Lavage w/ Suction- Benefits | Better cleansing w/ tunneling/undermining; Rx site-specific; Tx at bedside; Tx at home; Safer; More comfort; Cost saving; Better control; Easier sharp debridement after PLWS; Increased granulation/epithelialization; Decreased granulation development time |
| PLWS Indications/Contraindications | I: Open wounds (infected, necrotic, or granulated) C: Inexperienced PT, Pt allergic to latex |
| PLWS Precautions | Know anatomy; Wound w/ tunneling & undermining bleeding; Wounds near major vessels/exposed nerve, tendon, bone Facial wounds; Skin grafts; Anti-coagulants; Bypass graft sites, anastomoses exposed vessel, nerve, tendon, bone grafts, flaps |
| PLWS PSI settings guidelines | 2-6 PSI for initiation of tx & when treating tunnels/undermining that can't be visualized; 8-12 PSI for most wounds; 12-15 PSI for infected wounds |
| PLWS Suction setting guidelines | 60-100 mghg continuous mode |
| When to change PLWS settings | Decrease PSI if bleeding, c/o pain, or tip is near major vessel, nerve, tendon, bone, or cavity lining; Decrease suction when near vessel, in tunnel, or near cavity lining, bleeding or c/o pain |
| Solutions for PLWS | Normal saline for irrigation fluid Antibiotics may be used, but must be ordered by MD Warm bags for pt comfort & optimal wound healing |
| PLWS Methods | Infection control Comply with OSHA Comply with facility policies |
| General recommendations for personal protective equipment (PPE) when performing PLWS | Mask & face shield Hair covering- including ears Fluid-proof gown- long sleeves- knee high Fluid resistant boots Gloves that cover gown cuffs |
| Frequency of PLWS | Daily- when <50% necrotic tissue BiD- when >50% non-viable tissue, purulent drainage, foul odor &/or sepsis Every other day or 3x+ weekly- when full granulation base, no odor, no purulent drainage, & those being treated with VAC |
| Duration of PLWS | Treated until: Closed by 2ndary intention; No s/sx necrotic tissue/infection; No decrease in necrotic tissue/no increase in granulation/epithelialization after 1 wk tx (stagnant wound) |
| Discontinue PLWS & notify MD when... | Arterial bleeding; Bleeding not stopped within 10 mins of pressure; Abscess other than the one being treated is opened; Joint is disarticulated |
| Outcomes & Expectations of PLWS | 3-7 days: odor & exudate free 1 week: progress from chronic to an acute inflammation to proliferation 2 weeks: free of necrosis |
| Enzymatic Mechanical Debridement | Use of enzymes to promote solubilization of devitalized tissue |
| Methods/Procedures Enzymatic Debridement | MD order & prescription- can't do it on your own; Cleanse wound with saline; Escharotomy if eschar present; Apply thin film of enzymatic agent; Cover with gauze moistened with saline; Topical antibiotics often applied to prevent bacteria in bloodstre |
| Frequency & Duration of Enzymatic Debridement | Follow directions from product manufacturer |
| Advantages & Disadvantages of Enzymatic Debridement | A: Less traumatic & more selective than mechanical debridement; more cost-effective D: Slower than sharp debridement & PLWS |
| Autolytic Mechanical Debridement | Moisture- retentive dressings to create environment for macrophage, neutrophil, & other phagocytic cells to digest devitalized tissue (use moisture to remove extra slough) |
| Safety with ALL wound care | Standard precautions (i.e. glove, clean technique); Compliance with facility safety procedures; Compliance with OSHA (i.e. special containers for sharps & waste) |
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