Wound Debridement Introduction: Wound Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing

potential of the remaining healthy tissue. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars may also require debridement to promote healing. Anatomy and Physiology The integumentary system is formed by the skin and its derivative structures. The skin is composed of 3 layers: the epidermis, the dermis and subcutaneous tissues. 1. Epidermis- consists of a specific constellation of cells (keratinocytes), which function to synthesize keratin. (key of structural material making up the outer layer of human skin) a. Basal layer- aka stratum germinativum, contains column-shaped keratinocytes that attach to the basement member zone perpendicular to the dermis. Primary location of mitotically active cells in the epidermis that give rise to cells of the outer epidermal layers. b. Squamous Cell Layer- layer of the epidermis that overlie the basal cell layer Aka stratum spinosum c. Granular Layer- most superficial layer of epidermis containing cells 2. Dermis- the middle layer; made up of collagen. It lies on the subcutaneous tissue. 3. Hair follicles- protection from the elements and distribution of sweat gland products 4. Sebaceous Gland

TYPES:

1. Autolytic (Self- Digestion)

uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. *eschar-piece of dead tissue that is cast off from the surface of the skin (scab) Autolytic debridement is selective; only necrotic tissue is liquified. virtually painless for the patient. can be achieved with hydrocolloids, hydrogels and transparent films. (wound dressings) takes advantage of the body's own ability to dissolve dead tissue. The key to the technique is keeping the wound moist, which can be accomplished with a variety of dressings. These dressings help to trap wound fluid that contains growth factors, enzymes, and immune cells that promote wound healing. Autolytic debridement is more selective than any other debridement method, but it also takes the longest to work. It is inappropriate for wounds that have become infected.

2. Mechanical debridement
In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as nonliving tissue. Because

mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healing cells isalready developing.

3. Enzymatic (Chemical) Debridement

makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. As with other debridement techniques, the area first is flushed with saline. Any crust of dead tissue is etched in a crosshatched pattern to allow the enzyme to penetrate. A topical antibiotic is also applied to prevent introducing infection into the bloodstream. A moist dressing is then placed over the wound.

4. Surgical debridement
also known as sharp debridement, uses a scalpel, scissors, or other instrument to cut necrotic tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The physician starts by flushing the area with a saline solution, and then applies a topical anesthetic or antalgic gel to the edges of the wound to minimize pain. Using forceps to grip the dead tissue, the physician cuts it away bit by bit with a scalpel or scissors. The physician may repeat the process again at another session.

5. Biological debridement
Maggot therapy is a form of biological debridement known since antiquity. The larvae of Lucilia sericata (greenbottle fly) are applied to the wound as these organisms can digest necrotic tissue and pathogenic bacteria. The method is rapid and selective, although patients are usually reluctant to submit to the procedure.

Diagnosis/Preparation The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The assessment addresses the following points: the nature of the necrotic or ischaemic tissue and the best debridement procedure to follow the risk of spreading infection and the use of antibiotics the presence of underlying medical conditions causing the wound the extent of ischaemia in the wound tissues the location of the wound in the body the type of pain management to be used during the procedure Before surgical or mechanical debridement, the area may be flushed with a saline solution, and an antalgic cream or injection may be applied. If the antalgic cream is used, it is usually applied over the exposed area some 90 minutes before the procedure. INDICATIONS: 1. Necrotic tissue that would impair wound healing

2. A clinical suspicion of infection 3. Exceptional tenderness at or adjacent to the wound Procedure: 1. 2. 3. 4. 5. 6. 7. Gather all necessary supplies. Inform the patient of the treatment plan, which includes wound debridement. Position the patient in a comfortable position that gives adequate access to the wound. Remove dressings. Put on sterile gloves and perform sterile preparation and draping of the wound area. Sharply cut away the non-viable tissue until bleeding tissue is encountered. Control bleeding initially with direct pressure; if bleeding persists, use silver nitrate cautery sticks or place a suture as needed 8. If the patient experiences pain, avoid further debridement in area that produces pain 9. Collect culture specimen if indicated 10. Pack the wound as needed, then dress.

Incision and Drainage Incision and drainage constitute the primary therapy for the management of cutaneous abscesses; antibiotic treatment alone is inadequate for treating many loculated collections of infectious material Abscess incision and drainage are most often outpatient procedures. Diagnostic Exams and Indications The majority of skin abscesses are reported to be tender and fluctuant or erythematous with induration. 1. Physical examination of the affected area may allow diagnosis of an underlying abscess on the basis of swelling, pain, redness, and fluctuance, when these findings are present. 2. Needle aspiration of a suspected skin abscess can facilitate the diagnosis of a localized abscess when physical examination is equivocal. 3. Bedside ultrasonography is a valuable adjunctive tool to identify localized areas of fluid under the skin that may represent an isolated area of infection; ultrasonography can also be used to measure the dimensions of the abscess. Once the diagnosis of an abscess is made, the next step is to determine whether incision and drainage are necessary. Most cutaneous are appropriate for incision and drainage when they are larger than 5 mm in diameter and are in an accessible location. PRE-OP Preparation: 1. Obtain informed consent. Discuss the procedure and its risks and benefits with the patient, be sure to discuss the possibilities of pain, bleeding, and scar formation with patients before obtaining consent. 2. Verify the patient. Identify the correct surgical site, obtain agreement on the procedure to be performed, and ensure availability of all necessary equipment. 3. Wash your hands with antibacterial soap and water before beginning the procedure. Make sure you wear gloves and a face shield at all times during the procedure to avoid exposure to bodily fluids. 4. Place all equipment within reach, on a bedside table. 5. Position the patient so that the area for drainage is fully exposed and easily accessible, while ensuring the patients comfort. Adjust the lighting to allow easy visualization of the abscess. 6. Apply a skin cleanser, such as chlorhexidine or povidone iodine, in a circular motion,starting at the peak of the abscess. 7. Cover a wide area outside the wound to prevent contamination of equipment.

8. Anesthetize the top of the wound by inserting a 25-gauge or 30-gauge needle just under and parallel to the surface of the skin. 9. Inject anesthetic into the intra-dermal tissues. Once the entire open bore of the needle is under the skin, use gentle pressure to infiltrate the skin with the anesthetic agent. You will note blanching of the tissue as the anesthetic spreads out. Continue with infiltration until you have covered an area over the top of the abscess large enough to anesthetize thearea of incision.

PROCEDURE 1. Hold the scalpel between the thumb and forefinger to make initial entry directly into the abscess. 2. Make an incision directly over the center of the cutaneous abscess; the incision should be oriented along the long axis of the fluid collection. You may feel resistance as the incision is initiated. 3. Steady,firm pressure will allow a controlled entry into the subcutaneous tissues. Purulent drainage will begin when the abscess cavity has been entered successfully. 4. Control the scalpel carefully during the stab incision to prevent puncturing through the back wall, which can lead to bleeding that is difficult to control. 5. Extend the incision to create an opening large enough to ensure adequate drainage and to prevent recurrent abscess formation; the incision may need to extend the length of the abscess borders. If aerobic and possibly anaerobic bacterial culture are necessary, use a swab or syringe to obtain a sample from the interior aspect of the abscess cavity. 6. After allowing the wound to drain spontaneously, gently express any further contents. 7. Use curved hemostats for further blunt dissection to break loculations and to allow the abscess cavity to be opened completely. 8. Insert a curved hemostat into the wound until you feel the resistance of healthy tissue, then open the hemostat to perform blunt dissection of the internal portion of the abscess cavity. 9. Continue to break up loculations in a circular motion until the entire abscess cavity has been explored. 10. Gently irrigate the wound with normal saline, using a syringe with splash shield or a needleless, 18-gauge angiocatheter, to reach the interior of the abscess cavity. Continue irrigation until the effluent is clear. 11. Using wound-packing material, such as 1/4- or 1/2-in. packing strips with or without, gently pack the abscess by starting in one quadrant and gradually working around the entire cavity. 12. Place sufficient packing material to keep the wallsof the abscess separated and to allow further drainage of infected debris.
POST- OPERATIVE WOUND CARE TREATMENT and MANAGEMENT: 1. Assess the entire patient, not just the wound. Systemic problems often impair wound healing. 2. Characterize the wound. Assess the following: size and depth of involvement and the extent of undermining; the appearance of the wound surface. 3. Ensure adequate oxygenation.

4. Ensure adequate nutrition. Address protein-calorie malnutrition and deficiencies of vitamins and minerals. (1.25-1.5g of CHON/kg of body wt and 30-35 cal/kg). Vitamin A promotes tissue repair, Vit. C & E are required for collagen synthesis. 5. Treat infection. 6. Remove foreign bodies. These may prevent healing of wounds. 7. Provide a moist (not wet) wound bed. This support autolytic debridement, absorb exudate and protect surrounding normal skin. 8. Manage pain. Consider using 2% topical lidocaine gel during wound care.

HYPEREMESIS GRAVIDARUM Hyperemesis gravidarum is a severe and intractable form of nausea and vomiting in pregnancy and is worse than morning sickness. It is a diagnosis of exclusion and may result in weight loss; nutritional deficiencies; and abnormalities in fluids, electrolyte levels, and acid-base balance. The peak incidence is at 8-12 weeks of pregnancy, and symptoms usually resolve by week 20. Anatomy and Physiology: Female Reproductive System produces the female egg cells necessary for reproduction. (ova/oocytes) External: 1. 2. 3. 4. Internal: 1. 2. 3. 4. Vagina- canal that joins the cervix to the outside of the body; aka birth canal Cervix- lower part of the uterus Uterus- hollow, pear-shaped organ; home of the developing fetus Ovaries- small, oval shaped glands that are located on either side of the uterus; produce eggs and hormones 5. Fallopian tubes- narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova to travel form the ovaries to the uterus Labia majora- enclose & protect the other external reproductive organs Labia minora- surround the openings to the vagina Bartholins Gland- located beside the vaginal opening and produce a fluid secretion Clitoris- where two labia minora meet. A small, sensitive protrusion.

Pathophysiology

Non-modifiable: Age

Modifiable: Pregnant woman

Increased level of Human Chorionic Gonadotropin

Increased estrogen and progesterone

Metabolic imbalances Nutritional deficiencies Severe nausea and vomiting

Altered sense of taste

Dehydration

Weight loss

Physical and emotional stress of pregnancy on the body

constipation

ketosis Decreased skin turgor

Diagnostic Exams

The doctor will perform a physical exam. Blood pressure may be low. Pulse may be high. There is weight loss and decreased skin turgor due to dehydration.

The following laboratory tests will be done to check for signs of dehydration: Hematocrit Urine ketones

Your doctor may need to run tests to rule out liver and gastrointestinal problems. A pregnancy ultrasound will be done to see if you are carrying twins or more, and to check for a hydatidiform mole. Discharge Planning: DIET 1. Avoid foods that make you feel sick to your stomach. Foods that have strong odors may cause nausea for some women. 2. Avoid having an empty stomach. Eat small meals often throughout the day. 3. Eat low fat, high protein foods. (eg. Lean meat, beans, chicken without the skin) 4. Eat bland foods such as dry toast, dry dereal, noodles and bread. Other bland foods are bananas, apple, rice and popcorn without butter. Avoid spicy and greasy or fried foods. 5. Eat crackers or dry toast before you get up from bed in the morning. Get out of bed slowly. Keep crackers or dry toast at your bedside. 6. Drink liquids between meals. Wait at least 30 minutes after eating before drinking liquids. Drink small amount of liquids instead. MEDICINES 1. Keep a current list of your medicines. Include the amounts, and when, how and why you take them. Use vitamins, herbs or food supplements only as directed. Some medicines may include: Vit. B6 & Anti-histamine- help decrease nausea and vomiting Anti- emetic medicine Vitamin and mineral supplements LIFESTYLE 1. Learn what triggers your nausea and vomiting or what makes it worse. 2. Rest as much as possible. Take naps or lie down whenever you feel tired.

Wound Debridement & Incision and Drainage (Surgery) Hyperemesis Gravidarum (OB)

Prepared by: Angeles, Annamarie B. BSN 4-1 Submitted to: Alexander Estanislao, RN