2007 Sa Sawma Wound Debridement Nov 07

7/27/2019 2007 Sa Sawma Wound Debridement Nov 07

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Wound debridement

Sue TempletonCNC Advanced Wound Specialist

RDNS SA Inc


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Definition

The removal of all devascularised

or infected tissue or foreign

material from, or adjacent to, a

wound with the aim of exposing

healthy tissue.

(Carville, 2001)


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Principles of wound management

Define wound aetiology Assessment and investigations: general and local

Determine long and short term objectives

Identify and where possible eliminate or control general factorsimpairing healing

Implement appropriate management regimen Wound bed preparation (TIME)

Regularly monitor, assess progress and adjust

management regime prn

Promote optimal outcomes Healing or Optimising quality of life


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Implement (local) management

Wound bed preparation

TT tissue viabilitytissue viability

DebrideDebride nonnon--viable tissueviable tissue

I infection and inflammation control

Look for clinical signs

Antimicrobials, antibiotics

M moisture control

Dressings

E edge of wound Regular measurements to determine closure rate


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When to debride

Some infections (eg necrotising fasciitis)

Eschar with separation of edges

Necrotic tissue eg tendon, fatSlough

Blisters (burst blisters must be debrided)

Foreign matter (eg road dirt)

Burns

Haematomas


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Why debride

Devitalised tissue (eg necrosis, slough,infection, haematoma) will inhibit wound

healing by:

Hindering adequate wound assessment

Slowing granulation

Inhibiting wound contraction Preventing epithelial cell migration

Encouraging bacterial growth

Possible cause of malodour


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Methods of debridement

Surgical

Conservative sharp (CSWD)

Mechanical

Autolytic

Chemical

Biological

Enzymatic


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Factors influencing method used

Type of injury

Wound aetiology

Location of wound

Extent of tissue damage

Size of wound & extent of devitalized tissue

Amount of exudate


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Factors influencing method used

Time available

Availability of resources

User skill, experience and training

Cost effectiveness

Environment & care setting

Co-morbidities

Patient wishes


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Autolytic debridement


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Most commonly used method Auto = automatic

Lytic = breakdown / lysis

Using contemporary or specialiseddressings to enhance or facilitate thebodys own processes

Uses fluid regulation to assist debridement

Some specialised dressings can be used

to enhance autolysis


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Can be used for wounds of all exudatelevels

Selective only non-viable tissue isbroken down

Should cause minimal discomfort

Easy to perform basic skills required


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Mechanical debridement


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Mechanical debridement

Using mechanical (traumatic) methodsto remove non-viable tissue

Gauze wet to dry saline soaks/packs

Whirlpool therapy or hydrotherapy

High pressure irrigation

Methods often not selectiveCan be painful

Limited use in current best practice


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Enhanced mechanicaldebridement

Can be performed by nurses with limitedexpertise or confidence

Good confidence builder towardsconservative sharp wound debridement

Excellent for removing loose tissue, dead

skin, some macerationTools:

Dry gauze (particularly rough woven gauze)

Plastic forceps (can be broken in half)


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Conservative sharp wound

debridement (CSWD)


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CSWD

Using sterile, sharp instruments toremove non-viable tissue without

causing pain or traumaExcision is usually within margins of

non-viable tissue - CONSERVATIVE

Surgical debridement techniques

usually extend beyond non-viable tissue


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Guidelines for CSWD

Have the skills and knowledge to

perform the procedure

Possess the assessment skills todetermine if CSWD is appropriate

Understand the relevant anatomy andphysiology of the anatomy involved

Be able to readily identify healthy and

devitalised tissues


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Gaining skills in CSWD

Watch others Get a mentor

Attend a clinic

Start with really loose tissue

Use scissors as first option (learn to use

a scalpel later as skills develop)The skills to perform the procedure can

only be developed by doing it!


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Performing CSWD

Explain the procedure and obtain consent

Ascertain the level of sensation in the area

Avoid tissue that is not easily identifiable

as insensate and avascular

Provide analgesia (systemic or local

eg EMLA) prior to procedure if necessary


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Performing CSWD

Use sterile, sharp metal instruments ie McIndoe or Adson +/- toothed forceps,

iris scissors, disposable scalpel

(do not use stitch cutters)

Avoid all vascular and supportingstructures (eg tendon)

Exercise caution at the wound margins

Ensure an adequate light source

Maintain an aseptic technique


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Performing CSWD

Be conservativeNever debride whatyou cannot see

Be prepared to control any bleeding

Silver nitrate sticks

Calcium alginate

Flush wound with saline before and afterDispose of instruments appropriately

Document procedure accurately


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When NOT to use CSWD

Densely adherent necrotic tissue withoutseparation of edges

Impairment to blood clotting or anticoagulanttherapy

Increased risk of bleeding or exposure of bloodvessels (eg malignant wound)

Non-infected, dry, ischaemic ulcer where poortissue oxygenation will not support healing

Terminally ill

Where debridement might result in uncontrolled orunexpected wound dehiscence


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Professional and legal aspects

All Registered Nurses are accountable forensuring they have adequate skills and

knowledge to perform competently

Nurses should be familiar with any

restrictions to practice which may affect

their ability to perform CSWD Nurses Act

Professional standards and conduct codes

Organisational policies and guidelines

Documents

2007 Sa Sawma Wound Debridement Nov 07