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Wound 2

Acute Care Debridement Lecture

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)
Created by: 1190550002
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