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CEN-PROTOCOL-61

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CEN-PROTOCOL-61

     Department & Location Protocol Number

    Nursing Cooperative Wide Conservative Sharp Debridement of Wounds Page 1 of 4

PURPOSE:

    To define the nursing assessment and management of wounds requiring sharp debridement.

    Conservative sharp wound debridement may only be done by RN who has received GHC training and

    supervision of performance evaluation by a certified wound care specialist recommend a minimum of five

    supervised opportunities to demonstrate this skill.

    Training and Competency Validation must be documented and is required to be part of the RNs personnel

    file.

RESPONSIBILITY STATEMENT:

    Individual performing conservative sharp wound debridement will provide documentation of education and

    competency.

    An order from the attending physician will be obtained before the procedure, or physician practice protocols

    will be in effect permitting the procedure.

DEFINITION:

    Conservative sharp wound debridement is the removal of loose, avascular (non-viable) tissue using surgical

    instruments (e.g., scissors, scalpel, forceps) without inflicting pain or precipitating bleeding.

SUPPORTIVE DATA:

    1. Debridement

    ? Facilitates visualization of the wound wall and base for accurate and thorough assessment and

    treatment.

    ? Reduces the bioburden (volume of pathogenic microbes) of the wound by removing necrotic tissue

    and foreign matter. Devitalized tissue supports bacterial growth with increased risk for wound

    infection.

    ? Controls and potentially prevents infections.

    ? Interrupts at the molecular level the cycle of the chronic wound so that protease and cytokine levels

    more closely approximate those of the acute wound (Schultz, 1999)

    ? Essential to optimal wound management

    ? Indicated for any wound, acute or chronic, when necrotic tissue or foreign bodies are present or

    when infected. (contraindications to debridement include arterial insufficiency, pressure ulcers on

    the heel/toes, ischemic wounds, or those with dry gangrene.

     (AHCPR, 1994; Goode and Thomas, 1997; Robson, 1997; Stotts and Hunt, 1997)

    2. Various forms of necrotic tissue

    ? Eschar is firm, dry, leathery appearance of desiccated and compressed tissue layers.

    ? Slough contains fibrin, bacteria, intact leukocytes, cell debris, serous exudate, and quanties of DNA.

    May be adherent to the wound bed and edges or loosely adherent and stringy. May appear brown,

    yellow, or gray. Slough, when dries and hardens, becomes eschar.

    3. Various methods of debridement include:’

    ? Selective Conservative (only necrotic tissue removed-no bleeding results)

    ? Non selective (viable as well as nonviable tissue is removed)

    Draft 53454422.doc Last Updated: 5/7/10

    Nursing Conservative Sharp Debridement of Wounds Protocol # Cooperative Wide Page 2 of 4

EQUIPMENT FOR SELECTIVE CONSERVATIVE SHARP WOUND DEBRIDEMENT

    Clean gloves-other PPE as appropriate Silver nitrate sticks Normal saline for irrigation

    Sterile Instruments (forceps, scalpel, scissors) Magnifying lens Disposable drape

    Sterile 4x4’s Sterile cotton applicators

CONTENT:

    PROCEDURE KEY POINTS

     TOPIC: General Debridement Guidelines

     1. Explain procedure to patient

    Prevent microbial contamination of supplies. 2. Hand hygiene prior to assembling supplies

    Establish separate clean and dirty. 3. Assemble supplies and prepare work surface

     4. Ensure adequate lighting and magnification

    Use red bag only if generating saturated bloody 5. Position bagged kick bucket or open bag on

    gauze or large amounts of tissue. surface for accessible disposal of waste

    6. Apply clean gloves. Gown and wear mask with Masks prevent touching of face and prevents eye protection when irrigating or using deposit of employee’s respiratory droplets on Dremel. Masks recommended but not required. wound site. 7. Position patient for procedure. Place blue pads Placing barriers under the wound site prevents or towels under wound site environmental contamination. 8. Remove old dressing and discard. Disposable wound drainage canisters are to be

    9. Cleanse site with normal saline sealed and placed in the biohazard container in the

    clinics, and inpatient setting. Home care may seal 10. Grasp loosely adherent nonviable tissue with them and place in patient’s home trash. forceps, pull tautly, exposing a clear line of

    dissection

    11. If eschar cannot be removed, using a scalpel

    blade carefully serrate eschar to allow penetration of topical debridement ointment Pain and bleeding are signs of viable tissue. 12. Cut or snip loose tissue Bleeding that requires immed. assistance: 13. Irrigate wound with normal saline (see Wound ? Bleeding you can’t see the source of Irrigation Procedure)

    ? Bleeding you can hear (squirting sound) 14. For minor bleeding

     ? Apply pressure for 10 minutes

     ? apply silver nitrate

     ? topical agents like gel foam

     17. Remove gloves and perform hand hygiene.

     18. If culture needed, don clean gloves and follow

    Prevent camera contamination. Place only on clean Wound Culturing Procedure

    surface and handle only after sanitizing hands or 19. Photograph and measure wound wearing clean gloves. Wipe with disinfectant after 20. On completion of procedure, bag waste, using. remove gloves and wash hands before exiting

    room

    21. Document and advise staff of status

P________/# (CEN-PROTOCOL-6/23 5/7/10

Nursing Conservative Sharp Debridement of Wounds Protocol #

    Cooperative Wide Page 3 of 4

    Neuropathic Ulcer

Principles of treatment include sharp debridement of the wound’s callous collar, establishing a clean wound

    base, covering and protecting the wound, and off-loading pressure of the affected foot.

    ? If necessary and appropriate to the wound, first remove all surrounding, dry, callus tissue via sharp

    debridement.

    ? Gently irrigate wound with Normal Saline. Wear gown, mask with eye protection, and gloves. ? Apply dressing coverage of non-adherent gauze, then afix 4X4 over the non-adherent gauze, wrap or

    cover to hold dressing in place (without occluding circulation or putting pressure on surrounding tissue.

    Communication

Physician will be notified immediately when:

    A. Possible contraindications to debridement

    1. Tunneling

    2. Excessive undermining

    3. Presence of gross purulence

    4. Abnormal findings

    5. Cellulitis

    6. Infection

    7. Complicated patient condition

    8. Bleeding tendencies

    9. Heel/toe eschar

    10. Ischemic wounds (poor arterial blood flow) B. Possible complications

    1. Bleeding without known source

    2. Bleeding in excess of 15 minutes

    3. Bleeding that is squirting

    C. When more extensive debridement is indicated (may need referral to surgeon)

    Documentation

A. Document in Patient Record summary of procedure:

    1. Physician order

    2. Time and date

    3. Condition of wound

    4. Problems during procedure

    5. Type of wound covering

    6. Extent/description of debridement

    7. Signature of person debriding

P________/# (CEN-PROTOCOL-6/23 5/7/10

    Nursing Conservative Sharp Debridement of Wounds Protocol # Cooperative Wide Page 4 of 4

REFERENCES:

    thBryant, R. (2000). Acute and chronic wounds: Nursing management. (6 ed.). Mosby, St Louis. Agency for Health Care Policy and Research, Public Health Service. Clinical Practice Guideline:

    Treatment of Pressure Ulcers. Number 15. December 1994.

    Fowler, E., et al. Using wound debridement to help achieve the goals of care. Ostomy/Wound Management.

    Volume 41, No 7A. August 1995, 23S-36S.

Written by: Gwenda Felizardo, BSN, CIC, RN, Infection Control

    Original date: March 2002

    Reviewed by: Jan Crosman, MN, ARNP, ONC, RN, Orthopedics

    Barb Fugleberg, MN, RN, Puget Sound Regional Division Administration

    Ruth Gregersen, PhD, RN, Home and Community Services

    Karen Severson, MSN, RN, Hospital System Practice and Process Improvement

    Carmen Suazo, MN, RN, Nursing Operations

    Reviewed/Revised date(s): 1/03, 1/05

    Administrative Approval: ______________________________________________

     Director, Nursing Resources

P________/# (CEN-PROTOCOL-6/23 5/7/10

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