Module 3: Debridement and Bandaging

what is selective debridement?

removal of specific areas of devitalized tissue, may include sharp, enzymatic, or autolytic debridement

what is nonselective debridement?

removal of nonspecific areas of devitalized tissue, may include mechanical and surgical debridement

what are the purposes of debridement?

• decrease bacterial concentration

• increase effectiveness of topical antimicrobials

• improve bactericidal activity of leukocytes

• shorten the inflammatory phase of wound healing

• decrease the energy required by the body for wound healing

• eliminate the physical barrier to wound healing

• decrease the wound odor

when tissue is red, what are the treatment goals?

protect the wound, maintain a warm and moist environment, and protect the periwound (gen don’t debride)

what is the treatment goals for yellow tissue?

debride necrotic tissue, absorb drainage, protect the periwound

what are the treatment goals for black wounds?

debride the necrotic tissue

what are the general indications for debridement?

• necrotic tissue

• foreign material

• residual topical agents

• blisters

• callus

what are the general indications to not perform debridement?

• granular tissue

• viable tissue

• stable, hard, dry eschar in ischemic limbs

• urgent need to surgical debridement (gangrene, osteomyelitis)

• electrical burns

• deeper tissue (muscle, tendon, ligament, capsule, fascia, bone, nerves, blood vessels)

what is sharp debridement?

use of forceps, scissors, curette, or scapel to remove tissue, is the fastest and most aggressive form of debridement

what are the indications for sharp debridement?

• large amount of necrosis, callus, or advancing cellulitis, sepsis, eschar

• may be used on wounds with any amount of necrotic tissue

• chronic wounds may require repeated bouts

what are the contraindications of sharp debridement?

• area cannot be visualized

• material to be debrided is unidentified

• uninfected ischemic ulcers with low ABIs

• patients who are immunosupressed, thrombocytopenic, or on anticoagulants

• patient with life threatening diseases

when should you stop sharp debridement?

when the clinican fatigues or the pain is not adequately controlled for the patient, extensive bleeding, if a new fascial plane is identified, or nothing remaining to debride

what is autolytic debridement?

use of body’s own enzymes to digest necrotic tissue with moisture retentive dressing, occurs automatically in acute wounds, and is the most conservative method of debridement (least invasive, least painful, easy to teach)

what are the indications of autolytic debridement?

• can be used on all wounds with necrotic tissue

• pts who cannot tolerate other forms of debridement

• home or long term care settings

• pts with open wounds in palliative care/hospice

what are the contraindications of autolytic debridement?

• infected or deep cavity wounds

• wounds that require sharp or surgical debridement

  • gangrene

  • necrotic tissue

when should autolytic debridement be terminated?

if necrotic tissue fails to decrease in expected amount of time (possibly as little as 72 hours)

what is enzymatic debridement?

a method that uses chemical agents or enzymes to facilitate the removal of necrotic or devitalized tissue from wounds, promoting healing and reducing infection risk. is a form of selective debridement that requires a physician’s prescription (collagenase the only FDA approved enzyme)

what are the pros of enzymatic debridement?

requires less skill than sharp or surgical debridement, less painful than other methods

what are the cons of enzymatic debridement?

higher rate of adverse effects (most significantly cellulitis), takes longer than other methods, and can be expensive

what are the indications of enzymatic debridement?

• infected and uninfected wounds with necrotic tissue

• appropriate if cannot tolerate sharp

• in home or long term care

• may be used intermittently with serial instrumental debridement in the care of chronic wounds

what are the contraindications of enzymatic debridement?

• wounds with exposed deep tissue

• facial burns

• calluses

• free of necrotic tissue

• wounds already being autolytically debrided

• used with dressings, topical agents, or solutions containing silver, iodine, acetic acid, or hydrogen peroxide

when should enzymatic debridement be terminated?

once satisfactory debridement has occurred, if devitalized tissue within the wound bed is not effectively reduced within 2 weeks of product use

when should crosshatching of eschar be performed?

when there is thick, adherent eschar that is preventing absorption of topical agents or limits the effectiveness of enzymatic debridement.(before autolytic and enzymatic debridement)

what is mechanical debridement?

use of force to remove devitalized tissues, foreign material, and debris. is nonselective and can be very painful

examples of mechanical debridement?

• wet-to-dry dressings

• pulsatile lavage

• scrubbing

• whirlpool

• wound cleansing

• hydrogen peroxide

• wound irrigation

what is biological debridement?

“maggot therapy”, FDA approved live medical device for debridement that is faster than autolytic and enzymatic debridement (larvae ingest the necrotic tissues and bacteria and are unaffected by antibiotics so can debride and treat infection at the same time)

pros and cons of biological debridement?

• may increase odor and exudate

• may increase granulation and epithelialization

• least preferred method of debridement of an infected ulcer

• most expensive method

what is surgical debridement?

use of scalpels, scissors, or lasers in sterile environment, performed by physician or podiatrist, allows for extensive exploration of wound bed and debridement of deeper structures

what are the indication of surgical debridement?

ascending cellulitis, osteomyelitis, extensive necrotic wounds, extensive undermining, necrotic tissue near vital organs/structures, sepsis

what are contraindication of surgical debridement?

• pts who are unlikely to survive procedure

• pts with palliative care plans

• with another form of debridement will suffice

what are the benefits of moist wound healing (facilitated by bandaging)?

heals 3-5 times faster, facilitates 3 phases of healing, traps endogenous enzymes for autolytic debridement, preserves endogenous growth factors, reduced patient pain complaints, results in more cosmetically appealing scar

what are the functions of wound dressings?

• create moist environment

• provide thermal insulation

• provide barrier to microorganisms

• control edema, hemostasis, eliminate dead space within wound bed

primary dressing vs secondary dressing?

Primary dressings are applied directly to the wound, providing coverage and protection, while secondary dressings are used over primary dressings to secure them and provide additional protection or absorption.

what is composite dressing?

are advanced wound dressings that combine primary dressings with secondary dressings

what does occlusive mean when referring to bandages?

impermeable to water, vapor, and bacterial

describe the characteristics of moisture retentive dressings

synthetic or organic dressings that are more occlusive than gauze, have different classes that vary in different absorptive capabilities, cost, durability, composition, and ability to allow gas exchange, and obtain/maintain a moist wound environment thus facilitating wound healing

when are moisture-retentive dressings contraindicated?

when infection is already present (with exceptions for semipermeable foams, alginates, and antimicrobial dressings)

describe the continuum of wound dressings (the occlusion continuum)

see image

what are the precautions of gauze dressings?

may require more force for removal, may leave residue or lint, if dehydrates will adhere to wound bed

how should roll gauze be applied?

at an angle, snugly but without tension

what are tefla dressings used for?

reserved for superficial and non-draining wounds

what are benefits of impregnated gauze dressings?

They provide moisture, minimize adherence to the wound, and reduce pain during dressing changes. (increase occulsiveness)

what are the precautions of gauze dressings impregnated with bismuth?

cytotoxic to inflammatory cells, may be sensitizing agent, may increase inflammatory response

what are the precautions of iodine-impregnated gauze?

cytotoxic, only mildly antimicrobial

what are semipermeable film dressings used for?

to prevent maceration, to prevent bacteria from entering the wound bed (will not adhere to wet or oily skin though)

what should semipermeable film dressings NOT be used on?

infected wounds, wounds with moderate to heavy drainage, patients with fragile or sensitive skin

describe the characteristics of sheet hydrogel dressings

• absorb minimal amount of fluid so used for minimally or moderately draining wounds

• permeable to gas and water and is less effective to bacterial barriers than semipermeable

• provides padding and decreases pressure and shear forces

• used on dry wounds to obtain a moist environment

what should sheet hydrogel dressings not be used on?

heavily draining wounds, bleeding wounds, or infected wounds (and skin sealant may be needed to protect the periwound), also propylene glycol is a common irritant so don’t use on ppl who are sensitive/allergic

describe the characteristics of semipermeable foam dressings?

used on wounds with minimal to heavy exudate, permeable to gas but not bacteria, provide thermal insulation, and gen reserved for granulating or slough covered partial and full thickness wounds, also used for donor sites, ostomy sites, minor burns, diabetic ulcers, and venous insufficiency ulcers

what are semipermeable foam dressings not indicated for?

• dry or eschar covered wounds

• arterial ulcers

• heel ulcers in bed bound pt

• patient with fragile skin integrity

• pts with know skin sensitivities to adhesives

describe the characteristics of hydrocolloid dressings

absorb exudate slowly and swell to a gel like mass, are impermeable to water, O2, and bacteria (making them an effective barrier against urine, stool, MRSA, hep B, HIBV-1, and pseudomonas)

what are common uses for hydrocolloid dressings?

partial and full thickness wounds, granular and necrotic wounds, pressure ulcers, minor burns, venous insufficiency ulcers, fill cavities of heavily exudating wounds

what are the precautions of hydrocolloid dressings?

likely to roll in high friction areas, need to watch for skin sensitivity

what are hydrocolloids not appropriate for ?

bleeding or heavily draining wounds, infected wounds, dry wounds, arterial ulcers, 3rd degree burns, or wounds with minimal drainage, wounds with exposed tendons/fascia, pt with poor skin integrity

describe the characteristics of alginate dressings

are highly permeable and non-occlusive, are made of salts from alginic acid from brown seaweed, create a moist wound environment that may trap bacteria and can be washed away during dressing changes, are available as sheets, ropes, or tipped applicators

what are alginate dressings appropriate for?

since absorb up to 20 times their weight, are appropriate for moderately to highly draining wounds, partial and full thickness draining wounds, packing cavity wounds, granular or slough covered wounds, but need to change daily on infected wounds

what are alginate dressings not indicated for?

• full thickness burns

• wounds with exposed tendons, joint capsule, or bone

• neonates born at before 38 weeks

what are good dressing options for infected wounds?

• gauze

• alginate

• semipermeable foam

need to change them all regularly still