Nurse Competency in Conservative Sharp Debridement of Non- viable Tissue in Wound Care Objective: Provides safe and competent nursing assessment and instrument debridement technique for patients with non-viable tissue in wounds



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Nurse Competency in

Conservative Sharp Debridement of Non- Viable Tissue in

Wound Care
Objective: Provides safe and competent nursing assessment and instrument debridement technique for patients with non-viable tissue in wounds.
The Louisiana State Board of Nursing, Nursing Practice Committee deliberated and formed the following opinions:
In reference to agenda item 4.4, it is within the scope of practice for registered nurses to perform sharp wound debridement provided said nurses have advanced specialized education (beyond basic) and technical skills documented in their files, and validation of technical skills on an annual basis. November 6, 1992
In reference to agenda item 6.1, that it is within the scope of practice for a registered nurse to perform bedside mechanical hydrodebridement with pulsed lavage (with pre-set psi range) when prescribed by a physician or other authorized prescriber, provided that the registered nurse has the necessary knowledge, skills, and abilities with documented competency to said registered nurse’s file. August 26, 1998

Debridement Competency for Lucretia German RN, C, CWOCN met not met N/A



1. Identify the patient.










2.a. Patient Assessment: Identifies the components of history pertinent to the wound and procedure to include: type and duration of the wound and or presence of necrotic tissue, underlying disease/condition, bleeding problems and allergies.










2.b. Determines the location of the peripheral pulses: femoral, popliteal, dorsalis pedis, posterior tibia and radial pulses.










3.a. Wound Assessment: Describe the wound/surrounding skin to include; color, size, drainage, odor, undermining, wound margins, location and depth.










3.b. Recognize abnormal values, findings, and clinical manifestations: cellulites, pain and wound infection










4. Photograph wound (optional)










5. Verify physician orders/referral/clinical judgment.










6. Explain the debridement procedure and purpose










7. Determine if pain medication is needed










8. Assemble necessary equipment










9. Position the patient.










10. Provide for adequate lighting










11.Wash hands










12. Prepare sterile field and equipment.










13. Don gloves.










14. Remove existing wound covering and discard.










15. Cleanse area with appropriate cleanser










16. With pick-up forceps and scissors, lift the necrotic tissue and remove it in layers with sharps.










17. Remove as much necrotic tissue as possible.










18. Recognize two types of bleeding to fear










19. Describe at least 3 methods to stop bleeding to include; pressure, silver nitrate sticks and topical agents.










20. Determine the aggressiveness of debridement to include: amount of necrotic tissue present, pain tolerance, fatigue and bleeding.










21. Determine when to stop debriding: i.e. impending exposure of tendon or bone, location of fascial plane, location of named structure, if field is obscured or bloody, when you get nervous.










22. Request re-evaluation from a physician when: patient febrile, no improvement, cellulites, abscessed area, major vessel encountered, or extensive undermined areas.










23. Post debridement care; Cleanse the wound with normal saline or cleanser and apply an appropriate dressing.










24. Documentation post debridement: record in the patient record on progress notes summary of the procedure: date and time, condition of the wound, problems during debridement and type of dressing used










______________________________Wound Care Nurse Signature ________Date
______________________________Physician Validation Signature ________Date
______________________________Chief Nursing Officer Signature ________Date


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