|
PROCEDURE FOR
DEBRIDEMENT OF WOUNDS
PURPOSE: To
remove necrotic tissue to facilitate wound healing
EQUIPMENT:
OPC Surgery Clinic
ACRC Head and Neck Oncology Clinic
Sterile suture set, instrument
pack
Instrument pack
Knife handle with #15
blade
All gauze 4X4s, sterile
Sterile bowl
Hydrogen peroxide 60 ml
Sterile 4X4 (all
gauze)
4X4's, tape
250ml irrigating saline
Non-sterile gloves
Burn dressing (all gauze 4X4, cling, tape) if
indicated
Culturette
Neomycin solution 0.1% for
wound
1% Lidocaine with epinephrine, buffered
Triple antibiotic ointment or Silvadene
cream, as
ordered
Towels, sterile (to be used as drapes if needed)
Sterile gloves
Culturette
ACRC Women's Oncology Clinic
Sterile tongue
blade
Sterile suture set
Prep solution if
needed
Sterile gauze 4X4's
Local anesthetic if
needed
250ml irrigating saline
Silvadene cream
Sterile gloves
Culturette
Sterile tongue blades
Local anesthetic, if needed
Tape
NURSING ACTION:
1.
Explain procedure to
patient: Necessary to prevent infection and promote clean base by
bathing and manual removal by instruments or enzymes applied topically.
2.
Vital signs pre and
post procedure.
3.
Assess for allergy
to local anesthetic.
4.
Document what area
was debrided.
5.
Assess patient
tolerance of procedure.
6.
Assess for evidence
of discomfort, bleeding or other adverse reaction.
7.
Label culture and
send to lab (if applicable).
8.
Document medications
given.
9.
Home health for
wound care.
10.
Give patient/family
discharge instructions regarding skin care.
PROCEDURE STEPS:
1.
Confirm
consent has been signed.
2.
Drape leaving
area exposed.
3.
Prep if
indicated.
4.
Adjust
overhead light.
5.
Set up
sterile field.
6.
Assist as
needed.
REFERENCES:
Lippincott Manual of Nursing Practice, 6th
edition, pp. 911-912.
Bryant, Ruth, Acute & Chronic Wounds: Nursing
Management, 2nd edition, 2002, pp. 157-175.
RESOURCE PERSON(S):
Donnella Doctor RN, MNSc, CWOCN; Amanda
Pennington BSN, RN, WOCN
|