Integumentary System

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Integumentary System Wound Symposium

• Wound Debridement

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Significance of Necrotic Tissue

• As tissues die, they change in color,
  consistency, and adherence to the wound bed.
• As NT increases in severity color changes from
  White/Grey to Tan or Yellow and finally to Brown
  or Black
• Consistency changes as tissues dessicate or dry
• Eventually NT becomes dry leathery and hard

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Significance of Necrotic Tissue

• Wound etiology influence clinical appearance
• Subcutaneous fat forms stringy, yellow slough
• Muscle Tissue degenerates into thick, tenacious
  tissue
• Hard Black Eschar Full-Thickness destruction
• Grey/Blueness or white devitalized tissue may
  represent prolonged ischemia

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Slough

• Yellow (or) Tan
• Thin, mucinous or stringy

Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md.
Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md.
5
Eschar

• Brown or Black
• Soft or Hard
• Full-thickness destruction
• The more water content present, the less
  adherent the debris is to the wound bed.

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Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md.
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Adherence

• Adhesiveness of debris
• Ease at which the two are separated
• NT becomes more adherent to the wound as level of
  damage increases
• Eschar more adherent than yellow slough

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Necrotic Tissue

• Retards Wound Healing
• Medium for Bacterial Growth
• Physical Barrier to Epidermal Resurfacing,
  Contraction Granulation
• More NT More Healing Time
• NT Obscures Visualization of the Total Wound

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Arterial/Ischemic Wounds

• NT may appear as dry gangrene
• Thick, dry, dessicated, black/gray appearance
• Firmly adhered to wound bed
• May be surrounded with a red halo

Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md
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Neurotrophic Wounds

• Usually no necrosis
• Often have hyperkeratosis surrounding the wound
• Hyperkeratosis
• looks like callus
• formation at the
• wound edges

(From Myers, B.A. (2004).Wound
Management Principles and Practice. Prentice
Hall, Saddle River, NJ)
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Venous Disease Wounds

• Either Eschar or Slough
• Yellow fibrinous material covers the wound
• Eschar might be
• due to dessication
• and or necrotic debris

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Pressure Sores

• NT relates to amount of tissue destruction
• Early stage of pressure ulcer, tissue may appear
  hard (indurated)with purple or black
  discoloration on intact skin (indicative of
  tissue death)

• Fitzpatrick, T.B., Johnson, R.A., Wolff, K.,
  Polano, M.K., Suurmond D. (1997). Color Atlas and
  Synopsis of Clinical Dermatology
• Common and Serious Diseases. McGraw-Hill Health
  Professions Division New York.

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Intervention Debridement

• Prevent bacteria from colonizing
• Prevent competition with viable cells for oxygen
  and nutrients
• Removal of necrotic and/or infected tissues that
  interfere with wound healing
• Debridement Irrigation are reported to be the
  most effective method of controlling wound
  colonization

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Appropriate Wounds for Debridement

• Partial or Full-thickness wounds
• Clinical Signs of Inflammation or Infection
• Periwound erythema
• Warmth
• Induration
• Edema
• Foul Odor
• Non-viable tissue or purulent exudate

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Clinical Considerations

• Viable wound and periwound tissues are adequately
  perfused with blood
• Precautions relative to introducing pathogens
  must be observed
• Debridement of dry eschar over a bone or tendon
  is contraindicated
• Debridement is contraindicated in the presence of
  dry gangrene
• Caution must be exercised when debriding a wound
  of a patient on anticoagulants

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Debridement

• Improves wound and soft tissue status
• Reduces risk of infection, complications, and
  secondary impairments
• Enhances Wound Healing
• With Debridement Wounds get Bigger Before They
  Get Better

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Identification of Tissue Types

• Skin
• Epidermisouter avascular layer
• 0.06 -.6mm thick, sloughs Q 30 days
• Waterproof keratinocytes are located in the
  epidermis
• New cells located in the basal layer

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Identification of Tissue Types

• Skin
• Basement Membrane
• Dermal-epidermal junction
• Separates and attaches the epidermis and the
  dermis
• Atrophies with aging (skin tears)

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Identification of Tissue Types

• Skin
• Dermis
• Provides support and nutrition for the epidermis
• Fibroblasts produce collagen for tensile strength
• Fibroblasts synthesize elastin for resiliency,
  produce other components of ground substance
  (GAGS, Proteoglycans, glycoproteins)
• Hair follicles, sweat glands, nails, blood
  vessels and nerves located in the dermis.

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Identification of Tissue Types

• Subcutaneous Layer
• Insulation
• Nutrition
• Cushioning
• Composed of
• adipose tissue
• Major vessels
• Lymphatics
• Nerves
• Easily Damaged by Pressure Infection

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Identification of Tissue Types

• Fascia
• Shiny white surrounds skeletal muscle
• Infection (e.g., necrotizing fasciitis) is spread
  easily along facial planes
• Precaution
• When fascial planes are separated or penetrated
  the risk of bacterial invasion increase.

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Identification of Tissue Types

• Skeletal Muscle
• Purpose is to provide function
• Protects bones, joints, nerves, and vessels
• Pads bony prominences
• Healthy muscle is dull red, contractile, and
  vascular
• Necrotic muscle is a darker dull red and
  avascular

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Identification of Tissue Types

• Bone
• If healthy, hard white
• Cortical bone covered with periosteum
• Periosteum is richly vascularized
• Provides surface for granulation tissue formation
• Accepts skin graft if healthy
• If exposed it will dessicate, turn yellow and
  will not allow for granulation
• If exposed, cortical bone must be kept moist or
  it will become necrotic

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Identification of Tissue Types

• Cartilage
• Connective tissue that covers and cushions the
  articular surface of bone at a joint.
• Poor vascularity

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Identification of Tissue Types

• Blood Vessels
• Arteries
• Arterioles
• Capillaries
• Venules
• Veins
• Understanding Anatomy is crucial to avoid damage

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Identification of Tissue Types

• Tendon
• Strong, elastic, fibrous tissues
• Attach muscles to bones
• When exposed can be identified by manually moving
  the adjacent joint
• Poor vascularity, become infected easily
• Must be kept moist if exposed
• Healthy tendons are shiny white and are covered
  with paratenon
• Paratenon carry blood, should not be debrided if
  healthy as the tendon will become necrotic
  without it.
• A necrotic tendon will not become viable again
• Loss of function results from loss of tendon

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Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md
28
Sussman, C., Bates Jensen, B. (2001). Wound Care
2nd addition. Aspen, Gaithersberg, Md
29
Debridement

• Removal of necrotic extraneous (foreign
  material, debris) tissue from a wound

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Purpose of Debridement

• Decrease bacteria within the wound bed,
  decreasing risk of infection
• Increase the effect of topical antimicrobials
• Improve the effect of inflammatory cells
• Decrease the length of the inflammatory phase
• Decrease the metabolic expense for healing
• Decrease the physical barrier to healing
• Decrease odor of the wound

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Types of Debridement

• Non-Selective
• Selective

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Non-Selective

• Mechanical Debridement
• Dry to Dry
• Wet to Dry
• Wet to Wet
• Dakins Solution
• Hydrogen Peroxide
• W/P
• Irrigation/ Lavage

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Selective

• Autolytic Use of bodys own endogenous enzymes.
  Apply a moisture retentive dressing/Saran Wrap.
  Wound fluid trapped beneath the dressing softens
  liquefies necrotic tissue. Growth factors and
  inflammatory cells may enhance healing as well.
• Least invasive, least painful, consist with moist
  wound healing model
• Contraindicated in infected wounds
• Enzymatic Use of topical exogenous enzymes to
  remove devitalized tissue
• Elase, Santyl, Accuzyme, Panafil
• Sharp/Surgical Scalpel, Forceps, Scissors

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Autolytic Debridement Protocol
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
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Enzymatic Debridement

• Indicated for infected uninfected wounds with
  necrotic tissue
• In infected wounds, enzymes may be used with
  topical antimicrobial therapy (ex. Polymoxin B
  with Collagenase)
• Contraindicated
• Wounds with exposed deep tissues (ligament,
  tendon, capsule, bone, nerve, muscle, blood
  vessels)
• Discontinue after 2 weeks if NT is not
  effectively reduced

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Enzymatic Debridement Protocol
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
37
Talking Points

• Dry Eschar
• Cross Hatch or put dressing on to rehydrate
• Enzymes are tough to activate, do better in moist
  environment

From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
38
Sharp Debridement

• Removal of nonviable tissue with sterile
  instruments
• Physicians, Nurses, PA PTs
• No State Practice Act denies PTs the right to
  perform Sharp Debridement
• All PT Practice Acts are written broadly enough
  to allow PTs to perform wound debridement
  without restriction
• Arkansas, Arizonia, California, Colorado, Hawaii,
  Montana, New Hamshire, New Mexico, Nortyh
  Carolina, South Carolina, Tennessee, Texas and
  Utah specifically cite wound debridement in their
  PT Practice Acts
• PTAs cannot perform sharp debridement

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Indications for Sharp Debridement

• Large Amount of Necrotic Tissue
• Advancing Cellulitis or Sepsis
• Thick Adherent Eschar

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Red Yellow Black Color Code

• Red
• Pale pink to beefy red, granulation tissue
• Goals Protect wound, Maintain warm moist
  environment, Protect periwound
• Yellow
• Moist Yellow Slough, may vary in adherence
• Goals Debride necrotic tissue, Absorb drainage,
• Protect Peri-wound
• Black
• Thick, Black, adherent eschar
• Goals Debride necrotic tissue

Cuzzell, J.Z. Am J. of Nursing (1988)
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Indication Contraindications

• Debride
• Necrotic Tissue
• Eschar, Slough
• Foreign Material
• Debris
• Residual Topical agents
• Blisters
• Callus

• Do not debride
• Granular Tissue
• Viable tissue
• Stable heel ulcer
• Gangrene, osteo
• Electrical Burns
• Deeper Tissues
• Muscle, tendon, ligament, bone, nerves, blood
  vessels
• Avoid in patients with impaired clotting
  mechanisms

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Sharp Debridement

• Two Types
• Serial Instrumental Debridement
• Selective Sharp Debridement

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Serial Instrumental Debridement

• Uses
• Forceps and scissors
• Occurs over several visits
• Creates minimal bleeding
• Usually requires softening necrotic tissue,
  making it more amenable to debridement, by use of
  W/P, Irrigation, or Pulsatile Lavage
• Goal Remove loosely adherent necrotic tissue

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Selective Sharp Debridement

• Uses Scissors and/or Scalpel
• Cut along the border of viable non-viable
  tissue
• Usually, does not require prior tissue
  preparation
• Gelfoam or silver nitrate may be needed to
  control minimal bleeding
• Requires use of dry dressing for 8-24 hrs after
  debridement

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Contraindications to Sharp Debridement

• When area of debridement cannot be adequately
  visualized (tunneling or undermining)
• When material to be debrided cannot be identified
• When clinician is out of her or his comfort zone
• When competency has not been met
• Sharp debridement should not be performed on
  uninfected ischemic ulcers with low ABI
• Only physicians should sharp debride
  hypergranulated tissue

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Sharp Debridement Protocol
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
47
Use of Instruments Forceps are used to lift
devitalized tissue. Hold the scissors
parallel(level) to the specimen to avoid
piercing the specimen with the sharp end of the
scissors
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
48
Use of Scalpel Hold blade level (parallel) with
tissue to be debrided Debride in layers to
prevent incising healthy tissue Use forceps to
apply gentle traction to the devitalized
tissue
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
49
Termination of Sharp Debridement

• Clinician becomes fatigued
• Patient reports Increased Pain
• Patient is less tolerant to procedure
• Bleeding beyond minimal
• A new facial plane is identified
• All necrotic tissue has been removed

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Debridement Competency
(From Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall, Saddle
River, NJ)
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Surgical Debridement

• Performed by a physician or podiatrist
• Scalpels, scissors, or lasers
• Performed in a sterile environment
• Indicated
• Ascending cellulitis
• Osteomyelitis
• Extensive necrotic wounds
• Wounds with extensive undermining or where
  undermining cannot be determined
• When necrotic tissue is near a vital organ
• When the patient is septic

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References

• Arndt, A.A., Wintroub, B.U., Robinson, J.K.,
  LeBoit, P.E. (1997). Primary Care Dermatology.
  W.B. Saunders Company Philadelphia, Plate 5, 12,
  57-81.
• Du Vivier, A. (1995). Dermatology in Practice.
  Mosby-Wolfe New York, 1-11, 25, 53, 94, 97, 100.
• Fitzpatrick, T.B., Johnson, R.A., Wolff, K.,
  Polano, M.K., Suurmond D. (1997). Color Atlas and
  Synopsis of Clinical Dermatology Common and
  Serious Diseases. McGraw-Hill Health Professions
  Division New York.
• Myers, B.A. (2004). Wound Management Principles
  and Practice. Prentice Hall Upper Saddle River,
  New Jersey, 37-45, 369-391.
• Sussman, C., Bates-Jensen (1998). Wound Care A
  collaborative Practice Manual for Physical
  Therapists and Nurses. Aspen Gaithersburg,
  Maryland.
• Sussman, C., Bates-Jensen (2001). Wound Care A
  collaborative Practice Manual for Physical
  Therapists and Nurses (2nd ed.). Aspen
  Gaithersburg, Maryland.
• White, G.M., Cox, N.H. (2002). Diseases of the
  Skin A Color Atlas and Text. Mosby New York, 1,
  3, 5.