i bc27f85be50b71b1 (150 page)

Stage

Description

Reddened area on the skin with an intact epidermis

((

\'(found similar to a blister or abrasion on which the dermis is

exposed

JIJ

Wound that exposes subcutaneous tissue down to, bur nor through,

underlying fascia

IV

Wound that exposes muscle, bone, or other supporting structures,

such as tendon or joint capsule

Source: Dam from The National Pressure Ulcer Advisory Panel's Summary of [he

AHCPR Clinical Practice Guideline. Prcssure Ulcers in Adults: Prediction and Preven[ion. (AHCPR Publication No. 92-0047). Rockville, MD. May 1992.

484

AClJfE CARE HANDBOOK FOR PHYSICAL THFRAPISTS

depending on the policy of an individual facility. Physical therapists

should also verify state practice acts regarding their ability to perform

sharp debridement. Specific management considerations for physical

therapists who work with patients who have wounds are described at

the end of this chapter.

Wound Cleansing

Wound cleansing is not synonymous with wound debridement or

wound decontamination. The purpose of cleansing a wound is to

remove loosely attached cellular debris and bacteria from the wound

bed. In most cases, the use of sterile saline is effective and safe for

cleansing the wound surface.67,68 Many studies indicate that using

unsterile tap water does not increase the rate of infection and is appropriate to use to cleanse wounds.67 There are many commercial wound deansers that contain surfacranes. Surfactants help to break the bonds

between coneaminants, debris, and the surface of the wound.67 The use

of antiseptics is appropriate in the early management of acute traumatic wounds bllt is of little benefit in chronic wounds. They may be cytotoxic to living tissues and can delay healing.67.69.7o

The most nelltral solution that will meet the needs of the patient

should be used. Aggressive agents should be used only when indicated. For example, a bleaching agent may help to dry a heavily exudating wound. Cleansing should be discontinued when the majority of a wound bed is granulating or when re-epithelialization is occurring to avoid damaging new tissue.

Clinical Tip

•

If the water source is known or suspected to be contaminated, it should nOt be used for wound deansing.67 If the

physical therapist is unsure, the water can be culrured in

the hospital laboratory.

•

Sterile saline expires 24 hOllrs after opening the bottle

and must be discarded. A saline solution can be made by

adding 2 tablespoons of salt to 1 quart of boiling

water.67,69 This recipe may be an inexpensive alternative to

purchasing saline for the patient who will be deansing

wounds at home.

•

It is best to use cleansing materials at body temperature.

The application of a cold solution will reduce the temperature of the wound and may affect blood Aow.70

BURNS AND WOUNDS

485

•

Whirlpool, although commonly and perhaps habitually

used, does not cleanse the wound. The use of whirlpool jets

is actually mechanical debridement and therefore should be

used only if mechanical debridement is indicated.

Clean versus Sterile Technique

Although clean versus sterile technique remains somewhat controversial, clean technique is sufficient for local wound care to chronic wounds and is generally accepted in the medical community, because

the chronic wound is already contaminated and far from sterile. Sterile technique is typically reserved for surgical and acute traumatic wounds.71

Sterile technique, which includes the use of sterile instruments and

sterile gloves, should always be used when invading the blood stream,

as with sharp debridement. Otherwise, the use of clean gloves is sufficient. Additionally, originally sterile dressings, once opened, can still be used as long as they are kept in a clean, controlled area.'!

Wound Debridement

Debridement has three primary purposes. The first is to remove

necrotic tissue or foreign matter from the wound bed, optimizing

healing potential. The presence of devitalized tissue prevents re-epithelialization and can splint the wound open, preventing contraction and closure. The second purpose is to prevent infection. The necrotic

tissue itself can be the source of the pathogenic organisms. The debridement of the slough and eschar also increases the effectiveness of topical agents. The third purpose is to correct abnormal wound repair.

Debridement is generally indicated for any necrotic tissue present in a

wound, although occasionally it is advantageous to leave eschar in

place. For example, eschar on heel ulcers that is firmly adherent to

surrounding tissue without inflammation of surrounding tissue and

without drainage and tenderness on palpation may not need to be

removed.72

There are two types of debridement: selective and nonselective.

Selective debridement removes nonviable tissue only and is indicated

for wounds with necrotic tissue adjacent to viable tissue. Methods of

selective debridement include sharp, autolytic, and enzymatic debridemenr. NOllselective debridement removes both viable and nonviable tissues. It is indicated in necrotic wounds with minimal to no healthy tissue. Mechanical debridement is a method of nonselective

debridcment.7l,73

486

ACUTE CARE HANDBOOK FOR I'HYSICAL TIIl:.RAIJI5T5

Selective Debridemelll

Sharp Debridement

Sharp debridement involves the use of scalpels, scissors, and forceps

ro remove necrotic tissue. It is a highly skilled technique best performed by or under the direct supervision of an experienced clinician.

(Note: Nor all states and facilities allow physical therapists to perform sharp debridement. ) Because rhe true selectiviry of sharp debridement depends on the skill of the clinician, sharp debridement can also result in damage to healthy tissues that can cause bleeding and a risk

of infecrion. Sharp debridement is especially expedient in the removal

of large amounts of thick, leathery eschar. Removal of eschar is

important in the patient who is immunocompromised, because rhe

underside of eschar can provide a medium for bacterial growth. Sharp

debridement has been shown to increase the degree of wound healing

when combined with the usc of a topical growth factor."

Sharp debridement can be painful; it is therefore recommended