RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineDebridement: Removal of devitalized tissue and foreign matter from a wound. Various methodscan be used for this purpose:Autolytic Debridement: The use of synthetic dressings to cover a wound and allow eschar to self-disgestby the action of enzymes present in wound fluids (AHCPR, 1994).Biological Debridement: The use of sterile larvae of Lucilia seicata (greenbottle fly) to remove non-viabletissue from the wound bed (Sibbald, Orsted et al., 2006).Enzymatic (Chemical) Debridement: The topical application of proteolytic substances (enzymes) tobreakdown devitalized tissue (AHCPR, 1994).Mechanical Debridement: Removal of foreign material and devitalized or contaminated tissue from awound by physical forces rather than by chemical (enzymatic) or natural (autolytic) forces. Examplesare wet-to-dry dressings, wound irrigations, and whirlpool (AHCPR, 1994).Sharp Debridement: Removal of foreign material or devitalized tissue by a sharp instrument such asa scalpel. Laser debridement is also considered a type of sharp debridement (AHCPR, 1994).Dehiscence: Separation of the layers of a surgical wound (AHCPR, 1994).Deterioration: Negative course. Failure of the pressure ulcer to heal, as shown by woundenlargement that is not brought about by debridement (AHCPR, 1994).Disinfection: A process that eliminates many or all pathogenic microorganisms on inanimateobjects, with the exception of bacterial spores. Disinfection of pressure ulcers is neither desirable norfeasible (AHCPR, 1994).Donut-Type Device: A rigid, ring-shaped device created to relieve pressure on the sittingsurface. This device is not recommended, because even though pressure is relieved in the tissue overthe centre of the ring, pressure in tissue resting on the ring causes vascular congestion and mayimpede circulation to the tissues (AHCPR, 1994).Dynamic Devices: Outdated term traditionally used to refer to devices that change supportcharacteristics in a cyclical fashion (AHCPR, 1994)Electrical Stimulation: The use of an electrical current to transfer energy to a wound.The type of electricity that is transferred is controlled by the electrical source (AHCPR, 1994).Epithelial Tissue: Outer-most layer of skin, which is avascular and has 5 layers which isconstantly being renewed every 45-75 days.71