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CHAPTER 32 Skin Integrity & Wound Healing
■ Many stage 4 pressure injuries extend into the bone, so a bone biopsy is often performed at the same time. The biopsy will detect osteomyelitis, extension of the infection into the bone. Mechanical Débridement This may be performed via lavage (discussed in a preceding section), the use of wet-to-damp dressings, or hydrotherapy (whirlpool). ■ Wet-to-dry dressings are coarse gauze moistened with normal saline packed into the wound, allowed to dry, and then removed several times a day. This form of débridement was common once, but its use has declined because it causes pain and provides only nonselective débridement . That is, it removes not only debris but also healing granulation tissue. If you must use this method, medicate the patient before- hand with opioid analgesics. Rewetting the gauze aids in its removal and decreases the pain, but it also may eliminate the débriding action of the dressing change. ■ Hydrotherapy or whirlpool treatments are a vigor- ous form of nonselective débridement reserved for wounds with a large amount of nonviable tissue, such as burns. Hydrotherapy is usually performed in the physical therapy department once or twice per day. The wound is placed in a whirlpool containing tepid water for a prescribed amount of time (perhaps 5 to 15 minutes). The wound should not be exposed directly to the water jets. Risks include the following: ■ Increased risk for periwound maceration, con- tamination by waterborne infectious agents, and cross-contamination; strict adherence to infection control measures is essential. ■ Vasodilation, which may increase edema and con- gestion in patients with venous stasis; use hydro- therapy with caution. ■ Increased risk for burns in persons with diabetic neuropathies due to a decrease in sensory abilities. Enzymatic Débridement This uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. Enzymatic débridement is used for the removal of eschar in burn-related wounds and for taking off slough in pressure injuries, diabetic foot ulcers, and other complex and chronic wounds. It is less painful than traditional sharp débridement. To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the enzyme, and cover the wound with a moisture-retaining dressing. This procedure may be done once daily, depending on the product. Apply the product only to devitalized tis- sue because it might cause some local irritation. Certain cleansing agents can inactivate or slow the action of the enzymes. Autolytic Débridement (Autolysis) This is the use of an occlusive, moisture-retaining dressing and the body’s own enzymes and defense mechanisms to break down necrotic tissue. This process takes more time than
the other techniques, but it is better tolerated. The proce- dure involves applying the dressing and observing the fluid that collects under it (wound fluid may be tan in color). The dressing is normally changed every 72 hours, or sooner if drainage breakthrough occurs. At that time, the wound is cleansed before a new dressing is applied. Observe the wound closely and regularly for signs of infection, such as an increase in pain or a foul odor. Key Point: Autolysis is contraindicated in the presence of infection or immunosuppression. Biotherapy (Maggot) Débridement Therapy This is the use of medical-grade larvae of the greenbottle fly to dissolve dead and infected tissue from wounds. The larvae secrete enzymes that break down dead tissue. The enzymes are neutralized when they contact normal tissue, so healthy tissue is unharmed. The larvae also digest bacteria from the wound. This therapy is effective and simple to use, although containing the larvae within the dressing can be problematic. Larvae are usually changed every 48 to 72 hours and disposed of as biohazardous medical waste. Patients are likely to feel a nipping or pick- ing sensation at the application site. This can be painful. The use of maggots can be emotionally dis- turbing to both patients and nurses, so take this into consideration and discuss it with the patient (King, 2020). Providing Moist Wound Healing A physiological wound environment is one that main- tains the right amount of moisture for cells to flourish. The skin maintains the necessary balance of moisture by allowing moisture to evaporate as needed. With damage to the skin, body cells can dehydrate, so wound dress- ings must function as a barrier to water vapor loss. Choosing a Dressing When choosing a dressing, ask yourself whether it will achieve the purposes listed in the foregoing sections. Also consider how long the dressing should stay in place, how often it needs to be changed, and whether it can be removed without damaging fragile skin or the wound itself (Table 32-5). The type of dressing used on a wound depends on the characteristics of the wound and the goals of treatment. The dressing of choice should: ■ Prevent drying of the wound bed. ■ Absorb drainage.
■ Keep the surrounding tissue dry and intact. ■ Protect from contamination and infection.
■ Aid in hemostasis. ■ Débride the wound. ■ Eliminate dead space. ■ Prevent heat loss. ■ Splint the wound site. ■ Provide comfort to the patient. ■ Control odor. ■ Minimize scarring
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