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
|
|
|
|
