Interventions & Documentation

What info is part of the wound evaluation?

-Wound pathology

-Location and measurements

-Presence of necrotic and granunlation tissue

-Presence of exudate

-Stage of wound healing

What is the wound mgmt for a wound that is red?

-Protect

-Facilitate granulation and epithelialization

What is the wound mgmt for a wound that is yellow?

-Cleanse/debride

-Remove exudate or slough

What is the wound mgmt for a wound that is black?

-Debride

-Remove devitalized/necrotic tissue

Purpose of cleansing

Removes loose material from wound's surface:

-Exudate

-Slough

-Loss necrotic tissue

What wound cleansers are used?

-Normal saline: best way

-Commercial cleansers and surfactants

What is a surfactant?

Reduces bonds holding loose debris on wound's surface by decreasing surface tension

What are the methods of irrigation?

-Bulb and syringe irrigation

-Jet lavage: 'water pik': clean, not sterile, water; spray nozzle delivers stream; may be unable to calibrate impact pressure

-Pulsatile lavage w/ suction: hydropressure cleansing, decreased bacteria

-Whirlpool: rarely used; exposes orifices; non-selective; dependent position; clean, not sterile, water

Purposes/goals of debridement

-Dec wound bioburden/bacterial levels and risk of infection

-Increase effectiveness of topical antimicrobials

-Shorten inflammatory phase

-Eliminate physical barrier to healing

-Decrease energy required for healing

-Decrease wound odor

What are the selective debridement types?

-Sharp

-Enzymatic

-Autolytic

-Biological (maggot) therapy

What are the non-selective debridement types?

-Surgical

-Mechanical

What is surgical debridement?

-Performed by MD or podiatrist

-Fast and effective method to remove necrotic tissue

-For excision of excessive necrosis, bone or abnormal wound repair

-May continue to require debridement

Contraindications of surgical debridement

Medically unstable, no circulation

When surgical debridement not indicated?

Less than 70% necrosis or if life threatening

Advantages of sharps debridement (4)

-Serial vs selective

-Bedside treatment

-Removes only identifiable necrotic tissue

-Effective in combination with other techniques

Disadvantages of sharps debridement (2)

-Requires expertise/skill and specific education

-May be painful (due to tugging on intact tissue)

What to do w/ bleeding?

-Hold sterile gauze over area for 10 min

-DO NOT peek

-Silver nitrate sticks help w/ coagulation

What kinds of wounds would sharp debridement be best to use?

Dead tissue, good circulation; doesn't matter what body part it is on

What kinds of wounds would you not want to use sharp debridement on?

Someone w/ no BF, hemophilia, very high Coumadin, very anxious, combative, extremely cognitively impaired

What are the types of mechanical debridement?

-Soft abrasion debridement w/ gauze

-Wet-to-dry dressings

-Hydrotherapy

-Negative pressure therapy

-Low frequency ultrasound

-Antimicrobial solutions

Advantages of soft abrasion debridement

-Effective on loose nonviable tissue

-Prevent Epiboly

-Aggressive friction applied

Disadvantages of soft abrasion debridement

-Ineffective on eschar and adherent tissue

-Nonselective

-Painful on granulation tissue

-Precautions w/ anticoagulant-bleeding possible

Advantages of wet-to-dry

Removes loose tissue

Disadvantages of wet-to-dry

-Non-selective

-Performed incorrectly

-Painful

-Bleeding

-Desiccation of wound bed

-Time intensive and costly

What are the types of hydrotherapy?

-Whirlpool

-Syringe and needle irrigation

-Jet lavage

-Pulsatile lavage w/ suction

Advantages of whirlpool

-Cleanse wound of contaminants

-Softens eschar and other desiccated structures

-Local vasodilation

-Removes loosely adherent tissue

Disadvantages of whirlpool

-Time and labor intensive

-Non-selective

-Impact pressure unknown

-Cross-contamination

-Maceration

-Gravity-dependent position

Advantages of syringe and cannula irrigation

-Cleanse wound of surface contaminants

-9 PSI

-Removes loosely adherent tissue

Disadvantages of syringe and cannula irrigation

-Can be messy: use PPE

-Non-selective

-9 PSI too low for tracts or undermining

Advantages of jet lavage

-Cleanse wound of contaminants

-Deodorize

-Removes loosely adherent tissue

Disadvantages of jet lavage

-Messy: need PPE

-Non-selective

-Impact pressure unknown and difficult to control (>15PSI)

-Ineffective w/ eschar

Advantages of pulsatile lavage w/ suction

-Cleanse wound of contaminants

-Removes loosely adherent tissue

-Site specific

-Bedside or treatment room

Disadvantages of pulsatile lavage w/ suction

-Non-selective

-Impact pressure difficult to control

-Cautions near organs or fistulas

-Portable suction required

-Aerosolization of bacteria

Advantages of negative pressure wound therapy

-Improve tissue perfusion

-Reduce bacterial count

-Drainage mgmt

-Moist wound environment

-Enhance granulation tissue development

Disadvantages of negative pressure wound therapy

-Non-selective

-Time consuming

-Caution near organs or fistulas

-Patient compliance

Autolysis uses:

The body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough

What is autolytic debridement?

Process by which the wound bed utilizes phagocytic cells and proteolytic enzymes to remove devitalized tissue

Advantages of autolytic debridement

-Most selective form of debridement

-Last painful

-Low cost

-Effective in combination with other techniques

-Slowest process: 72 hrs

Disadvantages of autolytic debridement

-Slower than surgical or enzymatic

-Caregiver education required to prepare for wound appearance, odor and exudate

-Normal slough is often mistaken as purulent drainage

Advantages of enzymatic debridement

-Selective

-Used in combination with other debridement techniques

-Less painful

-Used w/ infected wounds

Disadvantages of enzymatic debridement

-Often over-utilized

-Slow

-Can be expensive

-Silver and zinc will inactivate

What is used in chemical debridement?

-Silver nitrate

-Antiseptics

-Hypergranulation

-Epiboly

Advantages of biologic (maggot) therapy

-Ingest necrotic tissue

-Excrete proteolytic enzymes

-Antimicrobial

-Antibacterial

-Painless

-Reduction of odor

-Effective on pyoderma gangrenosum

Disadvantages of biologic (maggot) therapy

-Gross factor

-Slower than sharp or surgical debridement

-Expensive

Contraindications of maggot therapy

-Absolute: fistula, wound, connected to body cavity, rapid advancing tissue necrosis

-Relative: exposed vessel, bleeding tendency, difficult dissolving tissue

What factors should be documented?

-Wound classification

-Anatomic location

-Size

-Quality/type of tissue (before and after debriding)

-Structures exposed

-Edema

-Periwound tissue

-Drainage (amount, color, consistency, odor)

-Temperature

-Pain

-Treatment performed

-Education given to patient

Where would this info be placed in a documentation? Results of skin and wound examination: tests and measures

Objective

Where would this info be placed in a documentation? Description of intervention/treatments performed, includes pt education

Objective

Where would this info be placed in a documentation? Interpretation of results of exam: evaluation, PT diagnosis, goals

Assessment

Where would this info be placed in a documentation? Changes in wound status; revision of goals

Assessment

Where would this info be placed in a documentation? Planned future treatment/plan of care and discharge planning

Plan