Integumentary Conservative Sharp Debridementsection: 4.09

Integumentary – Conservative Sharp DebridementSECTION: 4.09

Strength of Evidence Level: 3__RN__LPN/LVN__HHA

PURPOSE:

To provide guidelines for conservative sharp debridement of wounds with necrotic tissue.

CONSIDERATIONS:

1. Conservative sharp wound debridement is the safe removal of loose, avascular tissue using surgical instruments (e.g., scissors, scalpel, forceps) without inflicting pain or precipitating bleeding.
2. Registered Physical Therapists and RNs who have been trained and possess the appropriate credentials may implement this procedure according to specific state practice acts.

2.Instrumental debridement is performed as a sterile procedure.

3.Contraindications to debridement include:

1. Clotting disorder (e.g., thrombocytopenia, long term use of anticoagulants).
2. Cellulitis involving tissue around wound.
3. Sepsis.
4. Lower-extremity ulcer caused by or complicated by ischemia
5. Densely adherent (dry, stable) eschar.

1. Debridement should not be done when densely adherent necrotic tissue is present and interface between viable and nonviable tissue cannot be clearly identified
2. A physician’s order specifically for debridement must be obtained prior to the treatment.

1. Conservative sharp debridement may be uncomfortable for the patient. Consider pain management interventions prior to initiating procedure.

10.Wounds may be debrided as often as necessary.

11.Debridement should be discontinued when:

a.The wound has 100% bed of granulation tissue and no signs or symptoms of infection.

b.No increase in granulation tissue from one weekly evaluation to the next evaluation.

c.The wound no longer has a viable interface between necrotic and viable or living tissue.

EQUIPMENT:

Sterile 4x4 gauze

Disposable debridement kit:

scalpel with #15 blade

forceps with teeth

curved iris scissors

Gloves (1 pair sterile and 1 pair non-sterile)

Absorbent under pads as needed to clean wound

Sterile saline

Dressing supplies as appropriate for wound

Protective wear (mask, goggles, gown, etc.) as appropriate for wound drainage

Sharps container

Disposable bags

Silver nitrate sticks (optional) or

Surgical Gelfoam (optional)

PROCEDURE:

1.Adhere to Standard Precautions.

2.Explain procedure to patient.

3.Review the physician’s orders.

4.Position and drape the patient for the procedure.

5Prepare sterile field. Open debridement kit, saline and all supplies needed for procedure.

6.Apply facemask, goggles and gown if the wound appears to have any pressure or fluid behind it. Apply non-sterile gloves.

7.Remove and dispose of existing wound dressing.

8.Don sterile gloves.

9.Cleanse area with antiseptic (Betadine or Hibiclens if iodine allergy).

10.Clearly identify tissue to be removed as avascular (grasp avascular tissue with forceps and hold it taut so that line of demarcation is clearly visualized).

11.Perform debridement.

12.Flush the wound with sterile saline after debriding.

13.Control any minor bleeding with pressure by using sterile gauze (4x4, etc.) or silver nitrate sticks or gelfoam.

14.Dress wound per physician’s orders.

15.Double bag all contaminated supplies. Dispose of all instruments in sharps container.

AFTER CARE:

1.Reposition patient in a comfortable position in bed or chair with no pressure on wound(s).

2.Instruct patient and caregiver, if available, in proper positioning and turning techniques to avoid friction, shear and pressure on wound(s).

3.Document procedure, condition of wound and patient’s response to treatment.

REFERENCES:

Ramundo, J. (2007). Wound Debridement in In R. Bryant and D. Nix (Eds), Acute and Chronic Wounds: Current Management Concepts (3rd ed.) P. 176-187. St. Louis, MO: Mosby.

Bates-Jensen, B. (2001). Management of Necrotic Tissue. In C. Sussman & B. Bates-Jensen (Eds.) Wound Care: A collaborative Practice Manual for Physical Therapists and Nurses (2rd ed.) P. 197-215. Philadelphia, PA: Lippincott Williams & Wilkins.

Rolstad, B. & Ovington, L. (2007). Principles of wound management. In R. Bryant and D. Nix (Eds), Acute and Chronic Wounds: Current Management Concepts (3rd ed., Rev., pp 258-304). St. Louis: Mosby.

Baranoski, S., Ayello, E., McIntosh, A., Galvan, L. & Scarborough, P. (2008). Wound treatment options. In S. Baranoski and E. Ayello (Eds), Wound Care Essentials: Practice Principles (2nd ed.) P.136-149. Philadelphia, PA: Lippincott Williams & Wilkins.

American National Pressure Ulcer Advisory Panel (NPUAP) & European Pressure Ulcer Advisory Panel (EPUAP). (2009). International Guideline: Pressure ulcer prevention: A Quick reference guide. Retrieved February 10, 2010 from:

Keast, D., Parslow, N., Houghton, P., Norton, L., & Fraser, C. (2007). Best practice recommendations for the prevention and treatment of pressure ulcers: Update 2006. Advances in Skin and Wound Care, 20, P.447-460.