Débridement: Pressure Ulcers, Burns, and Wounds
PREREQUISITE NURSING KNOWLEDGE
• Before wound débridement, the patient and wound should be assessed for underlying causes, patient’s physical condition, nutritional status, and current healthcare treatment plan, including medications.3
• Normal wound healing progresses through an orderly sequence of three overlapping phases: inflammation, proliferation, and reepithelialization and remodeling.
• The presence of necrotic tissue or debris interrupts the normal sequence of wound healing, retards healing processes, and provides a medium that promotes bacterial growth.4
• Acute wounds may be classified as either partial-thickness or full-thickness wounds. Partial-thickness wounds penetrate the epidermis and part of the dermis; partial-thickness wounds can be further described as superficial or deep partial-thickness wounds. Full-thickness wounds extend to all skin layers, the epidermis and dermis, and may penetrate subcutaneous tissues.3
• Pressure ulcers are defined as localized injury to the skin or underlying tissue usually over a bony prominence as a result of pressure.7 The National Pressure Ulcer Advisory Panel (NPUAP) staging system is used to describe pressure ulcers.1,7
Stage I: Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, but the area may differ in color from surrounding tissues.7
Stage II: Presents as partial-thickness loss of dermis as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.7
Stage III: Is described as full-thickness tissue loss. Subcutaneous fat may be visible; however, bone, tendon, and muscle are not exposed. Undermining and tunneling may also be present, as well as slough.7
Unstageable: Tissue injury that cannot be adequately assessed because of the slough or eschar covering the wound base. Wound débridement should occur before staging the tissue injury.1,7
Suspected deep tissue injury: A purple or maroon localized area of discolored intact skin or blood-filled blister from damage of underlying soft tissue from pressure or shear. The area may be painful, boggy, warmer, or cooler as compared with adjacent tissue.7
• Necrotic tissue is nonviable tissue and may range in color from whitish gray, tan, yellow, and finally progressing to black. Necrotic tissue nourishes bacteria and slows healing by retarding the inflammatory phase.4 It may lead to deeper penetration of bacteria into tissues, resulting in cellulites, osteomyelitis, and possible limb loss.5
• Débridement provides a mechanism of removal of necrotic tissue and reestablishes normal phases of wound healing.
• Vascular evaluation is essential before wound débridement. Inadequate perfusion may result in the wound extending into a deeper dermal or full-thickness wound after débridement.9 Pressure ulcers, burns, and chronic wounds may develop necrotic tissue that requires débridement for wound healing to progress.
• Débridement may be achieved with several methods2:
Surgical débridement: Fast and effective means of removal of devitalized tissue. Requires local anesthesia, use of sterile instruments, and conditions and availability of a qualified clinician.2,9 Large amounts of necrotic tissue may be removed. This may be considered in burn patients with large amounts of eschar or with necrotizing soft tissue infections (i.e., necrotizing fasciitis).5
Sharp débridement: Similar to surgical debridement, but local anesthesia may or may not be administered. Sharp débridement procedures should be performed only by qualified physicians, advanced practice nurses, and other healthcare providers (including critical care nurses) with additional knowledge, skills, and demonstrated competence per professional licensure or institutional standard.2,9 This kind of débridement may be done at the bedside, in a clinic, or at an office. Sharp débridement is best for adherent dry eschar with or without infection present. The bacterial count is rapidly reduced.4 Sharp débridement may be difficult on hard, dry wounds. Consider enzymatic débridement as first option.9 Sharp débridement should be discontinued in presence of pain, bleeding, or exposure of underlying structures.
Chemical (enzymatic) débridement: Highly selective method of removal of necrotic tissue. Relies on naturally occurring enzymes that are exogenously applied to the wound surface to degrade tissue. This is a slower process that requires a moist wound bed with adequate secondary dressing to absorb wound exudate. Enzymatic débriding agents may be selective or nonselective to viable tissues. Nonselective agents may be best for thick, leathery, adherent eschar. Selective agents may be best when excess protein buildup is present.6 Examples of wounds that may benefit from chemical débridement are a partial-thickness burn wound or unstageable pressure ulcer.
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