Wound debridement

Sue Templeton
CNC Advanced Wound Specialist RDNS SA Inc

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)

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 factors impairing 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

Implement (local) management

Wound bed preparation T tissue viability
Debride non-viable tissue

infection and inflammation control

Look for clinical signs Antimicrobials, antibiotics

M moisture control
Dressings

E edge of wound
Regular measurements to determine closure rate

When to debride
Some infections (eg necrotising fasciitis) Eschar with separation of edges Necrotic tissue eg tendon, fat Slough Blisters (burst blisters must be debrided) Foreign matter (eg road dirt) Burns Haematomas

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

Methods of debridement
Surgical Conservative sharp (CSWD) Mechanical Autolytic Chemical Biological Enzymatic

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

Factors influencing method used

Time available Availability of resources User skill, experience and training Cost effectiveness Environment & care setting Co-morbidities Patient wishes

Autolytic debridement

Autolytic debridement
Most commonly used method
Auto = automatic Lytic = breakdown / lysis

Using contemporary or specialised dressings to enhance or facilitate the bodys own processes Uses fluid regulation to assist debridement Some specialised dressings can be used to enhance autolysis

Autolytic debridement
Can be used for wounds of all exudate levels Selective only non-viable tissue is broken down Should cause minimal discomfort Easy to perform basic skills required

Mechanical debridement

Mechanical debridement
Using mechanical (traumatic) methods to remove non-viable tissue
Gauze wet to dry saline soaks/packs Whirlpool therapy or hydrotherapy High pressure irrigation

Methods often not selective Can be painful Limited use in current best practice

Enhanced mechanical debridement

Can be performed by nurses with limited expertise or confidence Good confidence builder towards conservative sharp wound debridement Excellent for removing loose tissue, dead skin, some maceration Tools:
Dry gauze (particularly rough woven gauze) Plastic forceps (can be broken in half)

Conservative sharp wound debridement (CSWD)

CSWD
Using sterile, sharp instruments to remove non-viable tissue without causing pain or trauma Excision is usually within margins of non-viable tissue - CONSERVATIVE Surgical debridement techniques usually extend beyond non-viable tissue

Guidelines for CSWD

Have the skills and knowledge to perform the procedure Possess the assessment skills to determine if CSWD is appropriate
Understand the relevant anatomy and physiology of the anatomy involved Be able to readily identify healthy and devitalised tissues

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!

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

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 supporting structures (eg tendon) Exercise caution at the wound margins Ensure an adequate light source Maintain an aseptic technique

Performing CSWD
Be conservative Never debride what you cannot see Be prepared to control any bleeding
Silver nitrate sticks Calcium alginate

Flush wound with saline before and after Dispose of instruments appropriately Document procedure accurately

When NOT to use CSWD

Densely adherent necrotic tissue without separation of edges Impairment to blood clotting or anticoagulant therapy Increased risk of bleeding or exposure of blood vessels (eg malignant wound) Non-infected, dry, ischaemic ulcer where poor tissue oxygenation will not support healing Terminally ill Where debridement might result in uncontrolled or unexpected wound dehiscence

Professional and legal aspects

All Registered Nurses are accountable for ensuring 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