When do you debride and when do you just leave a wound alone?

lsyorke, RN · Jul 31, 2009

One question asked what I would do with a diabetic foot ulcer. I picked debride it 3 times a day. The answer was use sterile technique to change do the dressing change.
The rationale for not debriding this wound is to allow for granulation to form. When would we have to debride a wound? And when do we allow it to granulate?
Also wet to dry and wet to damp dressing serve the same purpose, to debride and prevent infection correct?
Thank you again.

Wow.there's just so much wrong with this question that I don't know where to start. What kind of debriding are they talking about....

Sharp Debride- doctors only.

Wet to dry debriding...TOTALLY wrong and shouldn't be used ever.

What does the wound bed look like? If there's fibrin, slough or eschar it needs to be sharp debrided or no granulation will occur. Debriding promotes granulation tissue, it's doesn't inhibit it.

Sterile dressings for a chronic wound...nope, no sterile dressing required for a wound that isn't sterile, clean is just fine.

Wet to dry will not prevent/stop infection. In fact it can create trauma in the wound bed, damaging granulation tissue making infection a greater possibility.

You allow a wound to granulate if it's a clean wound bed. Keep it moist(not with saline) with a gel like Hydrogel, or Silvasorb gel(if you need the antibacterial properties of silver)

IcanHealYou · Jul 31, 2009

Wow.there's just so much wrong with this question that I don't know where to start. What kind of debriding are they talking about....
Sharp Debride- doctors only.
Wet to dry debriding...TOTALLY wrong and shouldn't be used ever.
What does the wound bed look like? If there's fibrin, slough or eschar it needs to be sharp debrided or no granulation will occur. Debriding promotes granulation tissue, it's doesn't inhibit it.
Sterile dressings for a chronic wound...nope, no sterile dressing required for a wound that isn't sterile, clean is just fine.
Wet to dry will not prevent/stop infection. In fact it can create trauma in the wound bed, damaging granulation tissue making infection a greater possibility.
You allow a wound to granulate if it's a clean wound bed. Keep it moist(not with saline) with a gel like Hydrogel, or Silvasorb gel(if you need the antibacterial properties of silver)

Yea I'm most likely wrong about it preventing infection but I remember reading that somewhere.

However Wet to dry dressing is used for debridement... according to www.woundcentral.com at least. I haven't looked in my book yet but I remember specifically from nursing school wet to dry is for debridement.

Only recently did I start to see wet to damp dressing on NCLEX questions.

So you're saying this question from NCLEX4000 is totally bogus yea?

Which intervention is essential when performing dressing changes on a patient with a diabetic foot ulcer?

1.Apply heating pad

2. Debride the wound 3 times a day

3.Using sterile technique during the dressing change

4. Cleaning the wound with a povidine - iodine solution

Here's the rationale:

The nurse shoudl perform the dressing change using sterile technique to prevent infection. Applying heat should be avoided in a client with DM because of the risk of injury. Cleaning the woudn with povidine - iondine solution and debreding the wound with each dressing chagne prevents the development of granulation tissue, which is essential in the wound healing process.

So either way someone is definitely wrong...

leslie :-D · Jul 31, 2009

regardless of what the latest evidence states, i would use sterile technique w/dsg changes.

would much rather err on the side of caution.

besides, where did this say it was a chronic wound?

leslie

IcanHealYou · Jul 31, 2009

regardless of what the latest evidence states, i would use sterile technique w/dsg changes.
would much rather err on the side of caution.
besides, where did this say it was a chronic wound?
leslie

It didn't i think lsyorke was "reading into the question" lol

arelle68 · Jul 31, 2009

Whoever is writing the questions isn't up on the latest wound care stuff. Isyorke? Yes, yorke is!

IcanHealYou · Jul 31, 2009

"If the goal is to maintain a moist environment for a clean granulating wound, it is important to not let the saline-moistened gauze dressing dry and stick to the healing wound. This is in direct contrast to the dressing technique that you use if the goal is to mechanically debride the wound using a saline wet-to-dry dressing. When wounds require debriding, such as a necrotic wound, you use wet-to-dry dressing technique."

Potter, P.A. & Perry, A. G. (2009). Fundamentals of nursing 7th Edition. St. Louis: Mosby Elsevier. , pg. 1312

I also read somewhere online that now hospitals are using wet-to-damp dressings. This is why I was thrown off when I first saw wet-to-damp on the NCLEX questions.

So what do you guys suggest I do for NCLEX?

Cassaundra · Jul 31, 2009

"If the goal is to maintain a moist environment for a clean granulating wound, it is important to not let the saline-moistened gauze dressing dry and stick to the healing wound. This is in direct contrast to the dressing technique that you use if the goal is to mechanically debride the wound using a saline wet-to-dry dressing. When wounds require debriding, such as a necrotic wound, you use wet-to-dry dressing technique."
Potter, P.A. & Perry, A. G. (2009). Fundamentals of nursing 7th Edition. St. Louis: Mosby Elsevier. , pg. 1312
I also read somewhere online that now hospitals are using wet-to-damp dressings. This is why I was thrown off when I first saw wet-to-damp on the NCLEX questions.
So what do you guys suggest I do for NCLEX?

Our mantra when I was in school is there is a major difference between NCLEX world and real world. For your tests you go by the book - not common practice.

IcanHealYou · Jul 31, 2009

So then my question still needs to be answered in NCLEX mode =/

jjjoy, LPN · Jul 31, 2009

Frustrating, huh? I HATED that instructors/NCLEX would explain the rationales as if "This is clearly the *only* possible correct answer any *reasonable* person could ever consider" when there were many instances where the answer was flat out wrong or involved a number of assumptions that WEREN'T spelled out or when more than one answer COULD be correct depending on how you interpret the often vague questions...

And I hated when instructors would then dismiss questions about the rationales by saying "if you use your critical thinking skills, it will make perfect sense!"

And when we tried to ask about how we'd handle something in the real-world, the instructors would plead that we "didn't have time and had to move on".... Arghh!!!

ibatwoman · Jul 31, 2009

Debridement is to clean the wound bed or edges to allow the wound to heal, if there is moderate amt of dead or nonviable tissue it needs to come out, either by scapel around a calloused diabetic foot for example, or forceps and scissors to clean the bed it self. Three times a day seems a bit much. wet to dry is not the choice, sometimes it can clean a chronic wound when it has stalled but it is not the choice treatment. Aseptic technique is what is used in clinics and home care, you can't be sterile in someone's home. Sterile is usually for surgical wounds in the hospital and that is a short period of time.

There are many types of dressings on the market which can "dry" ie absorb drainage from a wound, clean a wound, retain moisture and debride. There are products that can stimulate growth. Surgical debridement is a physician procedure; in Arizona a nurse can debride with scapel and forceps when they have obtained extra training through a certificate program. I hope you are giving the wound a chance to granulate. Wound care is a challange and what works for one patient may not work for another. I have Physical therapists that I call on ( they have helped me with my WCC/my debridement certificate and are signing me off on debridement for my hospital program) when I have questions or exhausted my treatment alternatives.

Wet to dry is really not a good choice, we have surgeons that dont want to give it up, so they dont do it as long. The Wound Institute has good learning tools, WCEI has good sites and the WOCN site; and Convatec.

tlc2u · Aug 2, 2009

op wrote:

one question asked what i would do with a diabetic foot ulcer. i picked debride it 3 times a day. the answer was use sterile technique to change do the dressing change.

which intervention is essentialwhen performing dressing changes on a patient with a diabetic foot ulcer?

1.apply heating pad

2. debride the wound 3 times a day

3.using sterile technique during the dressing change

4. cleaning the wound with a povidine - iodine solution

here's the rationale:

the nurse shoudl perform the dressing change using sterile technique to prevent infection. applying heat should be avoided in a client with dm because of the risk of injury. cleaning the woudn with povidine - iondine solution and debreding the wound with each dressing chagne prevents the development of granulation tissue, which is essential in the wound healing process.

so either way someone is definitely wrong...

so then my question still needs to be answered in nclex mode =/

in nclex mode the question didn’t ask “what” you would do with a diabetic foot ulcer. the question asked what “intervention is essential?”

answering this question in nclex mode can be done using test taking strategies from saunder’s nclex review book 3rd ed. pg. 28.

look for key words that indicate the need to prioritize?

questions that require prioritizing

common key words that indicate the need to prioritize

--best --highest priority --most important --vital

--essential --immediate --next

--first --initial --primary

a key word in the question is “essential”.

[color=#333333]definition of “essential” is --a basic, indispensable, or necessary element.

[color=#333333]http://dictionary.reference.com/browse/essential

looking at all the answer choices the only choice that is “indispensable” or a “necessary element” is answer choice 3. using sterile technique during dressing change. the nurse may or may not need to debride a wound although debriding would not be necessary for every wound it all depends on the condition of the wound. again povidone-iodine may or may not be needed for a wound. as diabetics (due to increased sugar in the blood and the pathophys of diabetic ulcers) have an increased risk for infection; then taking measures to prevent infection would be “essential.”

another of saunders test taking strategies would help here as well.

how to avoid reading into the question

1. read every word in the question and “specifically” determine what the question is asking

2. focus only on the information in the question.

(i notice you do the same thing i often do, which is, reading the question and then the answer choices and then end up focusing more on the answer choices than we need to) the reason i say this is; many of the questions you asked are in reference to the answer choices not in reference to the actual question. obviously we can fill in the gaps of our knowledge by researching for a better understanding of any answer choices that we have less knowledge of, however this is not needed to answer the question.

the rationale for not debriding this wound is to allow for granulation to form. when would we have to debride a wound? and when do we allow it to granulate?

[color=#003663]according to the following articles wounds would be treated differently according to their type (chronic vs acute), and (healable, maintenance, or non-healable) and their cause and any underlying disease processes.

(note: these articles are not 2009, there may be more current info available but these are excellent articles and i did not readily find any articles more current)

http://www.wocn.org/pdfs/wocn_library/position_statements/clvst.pdf

[color=#231f20]this document is a collaborative effort of the association for professionals in infection control and [color=#231f20]epidemiology, inc. (apic) and the wound, ostomy continence nurses society (wocn). its purpose is to review the evidence on which chronic wound care practice is based and to present approaches for chronic wound care management.

http://www.nursingcenter.com/prodev/ce_article.asp?tid=680386

[color=#003663]one of the most controversial issues in wound management is whether all wounds should be debrided-especially the use of active surgical debridement of necrotic heel ulcers. some clinicians advocate not debriding a heel ulcer if it has stable adherent eschar with no exudate or signs of infection (tenderness, slough around the edges, or febrile response without another identifiable cause). the theory is that the eschar acts as a protective barrier for the wound.[color=#003663]26[color=#003663] other clinicians, including brem et al,[color=#003663]25[color=#003663] believe that although caution is indicated, these necrotic heel ulcers should be debrided.

[color=#003663]black eschar develops on ischemic toes when blood flow to the extremity is decreased and oxygen deficiency produces necrosis and cell death. ischemic toes are nonviable and have no supporting blood supply, so they should not be debrided. if the underlying vascular insufficiency is not resolved, debridement may cause a dry inert gangrenous toe to convert into moist active gangrene with local bacterial invasion and limb-threatening proximal cellulitis.[color=#003663]27[color=#003663] patients with septicemia, in the absence of systemic antibacterial coverage, as well as medically unfit patients, should not have their wounds debrided.[color=#003663]3

http://findarticles.com/p/articles/mi_qa3977/is_200311/ai_n9342483/

diabetes, nutrition and wound healing

also wet to dry and wet to damp dressing serve the same purpose, to debride and prevent infection correct?

yea i'm most likely wrong about it preventing infection but i remember reading that somewhere.

i have read differing expert opinions on this. some experts say that debriding prevents infection by removing bad tissue that would otherwise be a breeding ground for bacteria. others say that debriding also disturbs and removes good granulating tissue needed for wound healing. i have also read expert opinions that keeping a diabetic wound wet or damp can lead to gangrene which can then lead to sepsis, sepsis can lead to death.

hope this helps.

tlc2u

and thanks for asking such good questions. i learn a lot by answering questions too.