Wound Bed Preparation

Question 1

Purposes for Debridement

Answer 1

Decreases bacterial concentration within the wound bed and risk of infection
Increase effectiveness of topical antimicrobials
Shorten inflammatory phase
Decrease odor
Eliminate barrier to wound healing
Improve bactericidal activity of leukocytes
Decrease energy needed for wound healing

Question 2

General Indications for Debridement

Answer 2

Removal of necrotic tissue, foreign material, debris, senescent cells
Removal of biofilm
Correction of wound edges including callous, hyperkeratosis, non viable borders, epibole
Removal of residual topical agent

Question 3

Red–yellow–black system

Answer 3

Black eschar, full-thickness
Yellow draining wound with slough
Red granular wound
Wounds may present with combination

Question 4

Slough- yellow fibrin debris :

Answer 4

moderate to high water content. Lies on top of wound and is generally moderately to lightly adhered

Question 5

Eschar- brown to black necrotic tissue

Answer 5

May be soft or hard. Occurs with full thickness tissue destruction

Question 6

Biofilm

Answer 6

Polymicrobial
Reach bacterial levels of critical colonization
Present in 60% of chronic wounds
Invisible, wound bed appear pink/red and viable

Question 7

General Contraindications

for Debridement

Answer 7

Avoid trauma to viable tissue
Do not debride heel ulcers with eschar if they do not have edema, erythema, fluctuance, drainage
Wounds that require surgical debridement
Electrical burns prior to physician assessment

Question 8

General Considerations

for Debridement

Answer 8

Characteristics of wound
Status of patient
Existing practice acts
Clinician’s knowledge and skill level

Question 9

Methods of Debridement

Answer 9

Autolytic
Enzymatic
Mechanical
Biological
Sharp
Surgical

Question 10

Selective Debridement

Answer 10

Sharp
Autolytic
Enzymatic

Question 11

Nonselective Debridement

Answer 11

Mechanical

Surgical

Question 12

What is autolytic debridement?

Answer 12

Body’s own enzymes

Question 13

What wounds would use autolytic debridement?

Answer 13

Stage III or IV wounds with light to moderate drainage

Question 14

How is autolytic debridement performed?

Answer 14

Performed by occlusive or semi-occlusive dressings (hydrocolloids, hydrogels, or films) which keep wound fluid in contact with necrotic tissue

Question 15

What tissue is targeted with autolytic debridement?

Answer 15

Selective, only necrotic tissue is liquefied
Painless
Slower than surgical debridement.
May macerate surrounding tissue.

Question 16

Indications of autolytic debridement:

Answer 16

All wounds with necrotic tissue
Patients who cannot tolerate other forms of debridement
Commonly used in home or long-term care settings

Question 17

Contraindications of autolytic debridement:

Answer 17

Infected or deep cavity wounds

Wounds that require sharp or surgical debridement

Question 18

Autolytic Debridement:

Procedure

Answer 18

Crosshatch eschar
Moisture-retentive dressings
Protect periwound

Question 19

Moisture-retentive dressings

Answer 19

~2 cm larger than wound

Keep on for 72–96 hours

Question 20

What is enzymatic debridement?

Answer 20

Form of selective debridement
Requires physician’s prescription
Selectively digests protein, collagen, and fibrin.

Question 21

Which wounds would use enzymatic debridement?

Answer 21

Wounds with a large amount of necrotic debris or eschar formation
Less painful for patients unable to tolerate sharp debridement

Question 22

What enzyme is used for enzymatic debridement?

Answer 22

Collagenase - only enzyme currently FDA approve

Question 23

Drawbacks to enzymatic debridement?

Answer 23

Expensive, requires prescription, requires frequent re-application and dressing changes
May cause inflammation or discomfort
Slower process than sharp debridement
Can be applied by caregiver not skilled in sharp debridement

Question 24

Enzymatic Debridement Indications

Answer 24

Infected and uninfected wounds with necrotic tissue
Appropriate if cannot tolerate sharp debridement
Appropriate in-home or long-term care

Question 25

Enzymatic Debridement Contraindications:

Answer 25

``` Wounds with exposed deep tissues Facial burns Calluses Wounds free of necrotic tissue Exogenous enzymes should not be applied to wounds being autolytically debrided ```

Question 26

Enzymatic Debridement: | Procedure

Answer 26

``` Follow manufacturer’s guidelines Physician’s prescription Crosshatch eschar Moist environment Observe for infection Topical antimicrobial therapy as needed Collagenase is deactivated by silver and iodine ions Apply 2mm thick Must be applied daily Must have a moist environment ```

Question 27

Mechanical Debridement

Answer 27

Use of force to remove devitalized tissue, foreign material, and debris Nonselective

Question 28

Kinds of mechanical debridement:

Answer 28

``` wet-to-dry dressings scrubbing wound cleansing wound irrigation pulsatile lavage whirlpool hydrogen peroxide ```

Question 29

Benefits of mechanical debridement:

Answer 29

Wounds with moderate amount of necrotic debris | Low cost

Question 30

Drawbacks to mechanical debridement:

Answer 30

May traumatize healthy tissue | Painful

Question 31

Wet-to-Dry Dressings

Answer 31

``` Apply saline-moistened gauze Allow to dry Tear away dressing Prior standard dressing Now many better options Only indicated for wounds with 100% devitalized wound bed ```

Question 32

Scrubbing:

Answer 32

High-porosity sponge, brush, or gauze Water or saline Contraindicated for granulating wounds Best used for highly contaminated superficial wounds/burns

Question 33

Temperatures for whirpool non-thermal

Answer 33

80-90

Question 34

Temperatures for whirpool neutral

Answer 34

92-96

Question 35

Temperatures for whirpool thermal

Answer 35

96-104

Question 36

Whirpool

Answer 36

Removes dirt and foreign contaminants Removes toxic residuals from topical agents Softens & rehydrates necrotic tissue Removes toxic residuals from topical agents

Question 37

Drawbacks to whirpool

Answer 37

Additives may be cytotoxic (proper concentration?) Force from jets may be traumatic (no evidence) Nonspecific mechanical debridement Appropriate for non-venous wounds with thick exudate and slough or infected wounds/abscesses

Question 38

Pulsative Lavage

Answer 38

``` Removes dirt and foreign contaminants, Softens necrotic tissue Removes toxic residuals from topical agents Nonspecific mechanical debridement 4-15 PSI ```

Question 39

Contraindications to pulsative lavage:

Answer 39

Contraindicated over granulation tissue | Caution/contraindication if on blood thinners

Question 40

Jet-ox

Answer 40

Mist of saline delivered by pressurized oxygen Gentle to wound Rehydrates necrotic tissue and gently debrides

Question 41

US Mist

Answer 41

Mist created by US Rehydrates necrotic tissue and gently debrides May provide benefits of US for wound healing as well as debride Possible aerosolization of contaminants

Question 42

Low Frequency Contact US

Answer 42

Utilizes currete with saline spray as coupling medium Low frequency US is powerful enough to liquefy adipose tissue and disrupt biofilm New units include suction

Question 43

Biological Debridement:

Answer 43

magoot therapy FDA-approved live medical device for debridement Seldom used in the U.S.

Question 44

How maggot therapy works:

Answer 44

Larvae release enzymes that degrade necrotic tissue Larvae ingests necrotic tissue and bacteria Larvae are unaffected by antibiotics

Question 45

Benefits of maggot therapy:

Answer 45

Faster than autolytic and enzymatic debridement May decrease odor and exudate May increase granulation and epithelialization

Question 46

Sharp

Answer 46

Selective, necrotic tissue only Use of forceps, scissors, or scalpel Fastest, most aggressive form of debridement May also be used to correct improperly healing edges, epiboly

Question 47

Indications of sharp debridement:

Answer 47

Large amount of necrosis, callus, advancing cellulitis, sepsis, eschar May be used on wounds with any amount of necrotic tissue Chronic wounds

Question 48

Contraindications of sharp debridement:

Answer 48

When area cannot be adequately visualized Material to be debrided is unidentified Lack of clinician competency Infected ischemic ulcers with low ABIs

Question 49

Precautions for sharp debridement:

Answer 49

immunosuppressed, thrombocytopenic, or on anticoagulants Wound closure is not consistent with POC Hypergranular tissue

Question 50

Sharp Debridement: | Termination

Answer 50

Lack of pain control Patient tolerance to technique Extensive bleeding

Question 51

Sharp Debridement: | Procedure

Answer 51

Scalpel and scissors parallel to surface Debride in layers Rinse wound with saline and reassess

Question 52

Surgical Debridement

Answer 52

Use of scalpels, scissors, or lasers in sterile environment Selective May be performed in OR or at bedside Typically large amount of necrotic or non-viable tissue or purulence May involve removal of viable tissue Often performed due to active infection

Question 53

Drawbacks of surgical debridement:

Answer 53

Painful Expensive Performed by physician or podiatrist Allows for extensive exploration of wound bed and debridement of deeper structures

Question 54

Indications for surgical debridement:

Answer 54

Ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining Necrotic tissue near vital organs/structures

Question 55

Contraindications for surgical debridement:

Answer 55

Patients who are unlikely to survive procedure | Patients with palliative care plans