Help with cleansing a necrotic/ischemic toe/foot?

[josephjohn87]

Question:

If a patient has PVD and diabetes and has a necrotic/ischemic toe, do you cleanse with normal saline or just paint with povidone?

My preceptor told me that you should never cleanse with normal saline, but did not tell me the rationale. Why? Why should I only pain with povidone?

Wound Care Nurses?? Please help? Thanks

[xoemmylouox, ASN, RN]

I would clean with whatever that patient's MD orders. Many treatments require this depending on your facility (standing orders, protocols, etc).

[Anna Flaxis, BSN, RN]

For an ischemic, non-healing wound with necrotic tissue that is not a candidate for sharp debridement due to the lack of blood supply: If there is any wound discharge or debris, I would cleanse with 0.9% NS and then paint with an antimicrobial agent such as povidone iodine or chlorhexidine.

I have no idea what your preceptor's rationale could be for "never" using NS.

Of course, I am not a wound care nurse, so there may be something that I am not aware of. Maybe someone else knows the answer.

[CodeteamB]

I would imagine that your preceptor is putting a focus on keeping the wound dry, and thus the ban on normal saline. A thin wash of iodine is different than the soakings I have seen given to wounds in the name of cleansing. Necrotic flesh when dry is manageable, get it wet, you have a mess on your hands. An order to only paint with iodine is not uncommon.

That said, If you don't understand the rationale the best person to ask would be your preceptor.

[Anna Flaxis, BSN, RN]

Okay, I wasn't thinking of soaking, but I could see how soaking the wound would be inappropriate.

It seems you could gently wash with NS, pat dry, and apply the topical, keeping the wound OTA.

Wound care experts? Am I completely out in left field here?

I agree you should ask your preceptor what the rationale is. "Because it's protocol" is not a rationale. Sometimes people don't tell you the rationale because they don't know. To me, learning the rationale for why we do things is an opportunity to educate oneself, so don't stop with your preceptor if s/he doesn't know. Find out the rationale for this and report back to us!

[nurseprnRN, BSN, RN]

There is a forum for wound care experts on AN-- consider posting there? I have always found them helpful.

[josephjohn87]

She told me it's because of risk for infection. If I wet the wound by cleansing with normal saline, I would soften the necrotic tissue and possibly spread an infection.

[josephjohn87]

Thanks.

[josephjohn87]

Thanks, but there was no order for it actually. I asked her later on, and she told me that getting it wet can loosen the necrotic tissue and may spread infection which is already bad for diabetic/pvd clients.

[Anna Flaxis, BSN, RN]

Thanks, but there was no order for it actually. I asked her later on, and she told me that getting it wet can loosen the necrotic tissue and may spread infection which is already bad for diabetic/pvd clients.

That makes absolute sense, which is why you wouldn't want to soak it, but does this negate a gentle rinse to remove loose debris as well?

[CodeteamB]

That makes absolute sense, which is why you wouldn't want to soak it, but does this negate a gentle rinse to remove loose debris as well?

In my experience (which has unfortunately included a large number of necrotic toes) yes. You want those babies to dry up and fall off. As yucky as a dry necrotic toe is a wet one is worse. It turns into a smelly, pulpy, shedding, bacteria factory and can lead to further infection in the foot.

In addition, there isn't much point in washing them. They are dead and beyond help. Loose debris will flake off into dressings and the toes themselves are fairly inoffensive provided you keep them dry.

So just a light coat of iodine (controls bacteria and aids in drying) and dry gauze dressings were the norm where I worked.

[Anna Flaxis, BSN, RN]

Thanks, that makes perfect sense.