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74 How toBecome anExpert inDebridement: Nurse Perspective
485
ness, including rehabilitation needs and potential
for self-management
ensures provision of timely and appropriate access
to treatment for the person with chronic or complex illness, demonstrating high level of clinical
condence and prociency
The seminal work of Patricia Benner (1982)
proposed a theory of the stages of prociency
moving from novice to expert, that represents a
systematic way of understanding how a learner, a
student, new or seasoned nurse develops skills and
understanding of a practice situation or event over
time [5] (see Table74.1). The theory proposes that
moving from novice to expert across ve stages is
not a strict linear one but one that may see the
learner move in a cyclical way as they reect on
their practice and learn additional knowledge and
skills. The model moves from the novice such as,
for example, a new student nurse, to the expert, for
example, the advanced nurse practitioner. The
advanced nurse practitioner has an extensive
knowledge of situations that allow for condence
and an intuitive grasp of complex patients situations, rules, guidelines or maxims are no longer
relied upon during the expert stage because the
individual is able to grasp the situation and understand what needs to be accomplished at this point
[5]. The nurse at all stages of the framework should
be cognisant of and supportive of a patient-centred
approach, so that all treatments are aligned with
patient goals [6]. The ve stages proposed in
Benner’s model have been mapped here against
the different types of debridement and represented
schematically in Fig.74.1.
To commemorate 2020 as the International
Year of the Nurse and Midwife, a systematic
review of the contribution of nurses as leaders in
research in the eld of wound care was completed [7]. This report clearly demonstrated the
increasing prole of nurses in the contribution to
research in the eld with the strongest contributions in the area of cohort studies, systematic
reviews and critically appraising the literature,
further supporting the domains of competence of
those in advance practice nursing. The authors
argue that nurse-led research seems to particularly support the work of nurses as frontline caregivers. Nurse research leadership in the eld of
Table 74.1 Stages of prociency. Adapted from Benner
(1982)
Potential strategies
for skills and
knowledge
Stage Denition
Novice The learner has had
no previous
experience making
them struggle to
decide which tasks
are more relevant to
accomplish
Advanced
beginner
Competent The learner has been
Procient The learner performs
Expert The learner grasps
The learner has
enough real-world
situations that the
recurrent component
is easily identied
when it is related to
rules and guidelines
on the job 2 or
3years and is able to
see actions in terms
of goals or plans and
works in an efcient
and organised
manner
by using pieces of
evidence that
provide direction to
see a situation as a
whole
the situation and
understand what
needs to be
accomplished
beyond rules,
guidelines, and
maxims
acquisition
Teach simple,
objective concepts/
attributes that are
easily identied
Increase assistance
and support in
setting priorities to
clients’ needs by
providing
guidelines for
recognising
patterns
Offer in-service
education or
opportunities
Use case studies to
stimulate critical
thinking especially
in situations which
principles or rule
that are
contradictory
Provide
opportunities for
experts to share
their skills and
knowledge and also
their analytical
abilities to solve
new situations
skin and wound care over the last 20years has led
>40% of the highest level of evidence publications in this time [7]. This is a signicant achievement when one considers the short time frame
within which nursing has moved to university led
degree programmes and the establishment of
advanced practice roles internationally.
It is argued that skills acquisition such as, for
example, sharp debridement is a more important
predictor of competency than time in role [8]. This
486
Autolytic Enzymatic MechanicalSharp Surgical
Undergraduate
student
Graduate
nurse
Specialist
nurse
Advanced
nurse
practitioner
Fig. 74.1 Novice to expert in nursing practice and debridement
G. Gethin
is important because when an individual is in a
position for a length of time, others may view the
person as competent or procient, but the reality
may be the opposite. Competent and procient
nurses will not approach or solve problems in the
same way due to past experiences [5]. Thus, the
expert nurse can perform the skills of debridement
but importantly has the knowledge and understanding to assess the situation and make decisions
as to the appropriateness of debridement and the
choice of debridement method.
It can be reasonably seen that the student nurse
as the novice has no prior knowledge or experience
of wound care, wound assessment, or wound
debridement. However, autolytic debridement is the
body’s own method to remove sloughy or devitalised tissue and can be facilitated by the application
of wound dressings such as hydrogels. This can be
taught easily and performed under supervision by
the novice. As one moves across the continuum of
debridement methods, an increasing level of skill
and knowledge as to the appropriateness of each
method is required (see Fig.74.1). This is achieved
through further education, learning from others and
as proposed by Benner, being increasingly exposed
to the situation at hand. The ‘expert’ nurse, most
often seen as the tissue viability specialist, has this
advanced knowledge and is well positioned to make
a judgement on the type of debridement that is nec-
essary and aligned with patient and treatment goals.
It should be noted that as shown in Fig.74.1, the
nurse does not perform surgical debridement as this
is beyond their scope of practice.
74.3 Conclusion
The decision to initiate wound debridement and
the choice of method depends on patient and
treatment goals, available resources, and the
knowledge, skills, and expertise of the attending
clinician. The nurse, working at an advanced
level of practice is fully competent and procient
to make such decisions and initiate treatment in
consultation with the patient. Nurses as expert
clinicians signicantly impact on patient care and
improve patient outcomes.
References
1. Dufeld C, et al. Does education level inuence
the practice prole of advanced practice nursing?
Collegian. 2021;28:255–60.
2. Begley C, et al. An evaluation of clinical nurse and
midwife specialist and advanced nurse and midwife practitioner roles in Ireland (SCAPE). Dublin:
National Council for the professional development of
nursing and midwifery in Ireland; 2010.
74 How toBecome anExpert inDebridement: Nurse Perspective
487
3. Holloway S, et al. Wound curriculum for nurses:
post- registration qualication wound managementEuropean qualication framework level 7. J Wound
Care. 2020;29:S1.
4. Gardner A, et al. Development of nurse practitioner metaspecialty clinical practice standards: a
national sequential mixed methods study. J Adv Nurs.
2021;77(3):1453–64.
5. Benner P. From novice to expert. Am J Nurs.
1982;82(3):402–7.
6. Gethin G, et al. Evidence for person-centred care
in chronic wound care: a systematic review and
recommendations for practice. J Wound Care.
2020;29(Sup9b):S1–S22.
7. Gethin G, etal. Nurses are research leaders in skin and
wound care. Int Wound J. 2020;17(6):2005–9.
8. Shirey MR. Competencies and tips for effective
leadership: from novice to expert. J Nurs Adm.
2007;37(4):167–70.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License (http://creativecommons.org/licenses/by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit
to the original author(s) and the source, provide a link to the Creative Commons license and indicate if you modied the
licensed material. You do not have permission under this license to share adapted material derived from this chapter or
parts of it.
The images or other third party material in this chapter are included in the chapter's Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
How toBecome anExpert
inDebridement? Physician
Perspective
KirsiIsoherranen andVirveKoljonen
75
75.1 Introduction
Debridement means removal of nonviable, i.e.,
necrotic, damaged, infected tissue or foreign
bodies to enhance healthy tissue healing. Wounds
with necrotic tissue will not heal until all the
necrotic tissue is removed. Debridement also
provides an opportunity to take a deep tissue
sample as a bacterial swab. Early and aggressive
debridement in wounds is claimed to be a cornerstone of wound care, and failure to use the optimal debridement method may lead to patient
suffering and increased costs of care [1, 2].
Instead of becoming expert only in the
debridement technical skills, you need to become
expert in determining different types of tissues, to
know what to remove and what to leave.
Nonviable tissues in (chronic) wounds include
slough, eschar, and macerated tissues. Viable tissues include granulation tissue, subcutaneous tissue, muscle, bone, tendon, and vascular
structures.
Wounds with different etiologies need different
and often personalized treatment regimens.
Atypical wounds, such as pyoderma gangrenosum
K. Isoherranen (*)
Helsinki University Central Hospital and Helsinki
University, Wound Healing Centre and Dermatology
Clinic, Helsinki, Finland
e-mail: kirsi.isoherranen@hus.
V. Koljonen
Department of Plastic Surgery, Töölö Hospital,
University of Helsinki, Helsinki, Finland
and vasculitic wounds, exhibit pathergy when
debrided with sharp instruments [3]. Arterial
wounds should not be debrided until comprehensive arterial evaluation by a vascular surgeon has
been conducted [4]. Surgical debridement may not
be needed if the wound is not healable, e.g., in palliative care and wounds of non-adherent patients .
It must be noted that distinctive circumstances
such as systemic infection with wound infection as
focus may need on-call intervention. In patients
with diabetes or receiving immunosuppressive
therapy, signs of infection may be reduced or less
obvious, and these patients need a thorough and
proper assessment in order to exclude infection [5,
6]. Further, dark skin color may hamper detection
of redness in the skin. Therefore, other signs of
infection should be carefully monitored, and diagnosis of infection should be based on thorough
examination of the patient.
Thorough understanding of anatomy together
with proper tissue and instrument handling on
wounds that benet from debridement guarantee
a successful outcome. Importantly, attention
should be paid to wound edges and peri-wound
skin and they should be debrided as well if needed
[7]. There is no universal agreement on when and
how to debride or how much tissue to take [1].
The skills of debridement increase by exercise,
and to become an expert in wound debridement,
you only need to practice, practice, and practice
and to monitor the effect of your debridement.
Surgical debridement requires skills and training
in the operating room with a senior surgeon.
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_75
489
490
K. Isoherranen and V. Koljonen
75.2 How toDebride
Before debridement, a comprehensive and holistic patient assessment is mandatory. This includes
the diagnosis of the wound or skin necrosis to be
debrided. The patient should be informed carefully about the debridement process, and optimally an informed consent is obtained.
Information should include the benets and risks
of debridement and alternatives to treatment [7].
An expert in debridement knows the advantages and disadvantages of different debridement
methods (Table75.1) and can choose the optimal
debridement method for each situation.
75.2.1 Autolytic Debridement
Autolytic debridement means the process in
which the wound bed clears itself by utilizing
phagocytic cells and proteolytic enzymes, such
as collagenase, elastase, and lysozymes. This
process can be promoted by maintaining a
moist wound environment by hydrogels, honey
and by using occlusive dressings. Autolytic
debridement is the easiest form of debridement, and it is natural, selective, and usually
painless. Autolytic debridement does not damage healthy tissue and is claimed to promote
the formation of granulation tissue and epithelialization. However, it is a slow process and is
contraindicated in infected wounds [1, 2, 7]
(Table75.1).
75.2.2 Enzymatic Debridement
Enzymatic debridement contains the use of proteolytic enzymes that are able to digest cellular
debris of the wound bed. It can be a useful method
when mechanical debridement is contraindicated, for example, in patients with bleeding
problems (Table75.1). Side effects include pain,
burning sensation, and irritation of the periwound skin [1, 2, 7].
Table 75.1 Methods of debridement
Method of
debridement Advantages Disadvantages
Autolytic
debridement
Enzymatic
debridement
Biologic
debridement
Mechanical
debridement
Hydrosurgery Preserves as
Ultrasonicassisted
debridement
Surgical
debridement
Easy to perform,
does not require
special skills
Safe and
selective for
necrotic tissue,
does not damage
surrounding
tissues
Easy to perform
Works faster than
autolytic
debridement and
is also selective
for necrotic
tissue
Highly selective
and safe
Works well in
wounds
exhibiting
pathergy
phenomenon
Easy to perform,
no special skills
needed
Relatively quick
and painless
Faster than
autolytic and
chemical
debridement
much as possible
healthy tissues
Especially
feasible in burns
High precision
with little risk of
damaging viable
tissue
The fastest
method to obtain
a clean wound
bed
Works well in
wounds with
large amount of
necrotic material
and exudate
Slow process
Contraindicated in
infected wounds
May promote
anaerobic growth if
used with occlusive
dressings
Fairly expensive
May cause wound
pain and burning
sensation
Need to cross-hatch
eschar prior to
application of the
product
Expensive
Not recommended
in wounds
colonized with
pseudomonas
Can not be used
with compression
therapy
Not suitable in
wounds with hard
eschar
Nonselective
Risk of damage to
viable tissue
Disposable
handpieces and
tubing, thus
increasing the
carbon footprint
Risk of
crosscontamination
Requires analgesia
Requires skilled
clinician
May cause
bleeding and pain
may require
general anesthesia
75 How toBecome anExpert inDebridement? Physician Perspective
491
75.2.3 Mechanical Debridement
The use of wet-to-dry, plain, and parafn tulle
gauzes has been replaced by the newer and more
sensitive techniques such as the monolament
ber pad. A potential disadvantage of mechanical
debridement is that it is nonselective and can
remove viable tissue along with necrotic material
[7] (Table75.1).
75.2.4 Biological Debridement
Biological debridement or biosurgery includes
the use of larvae in the removal of devitalized tissue. In addition to debridement, the action of larvae is antimicrobial. Larval therapy can be
administered by “free range” maggots or by
using a biobag. Before applying the larvae into
the wound bed, they should be checked for activity. One of the major advantages of larval therapy
is the selectivity of maggots to separate the
necrotic tissue from live tissue (Table75.1). This
allows an easier surgical debridement.
Contraindications include usage near eyes, upper
gastrointestinal tract and upper respiratory tract,
and allergy to y larvae, brewer’s yeast, or soybean protein. Wounds with exposed blood vessels
and malignant wounds are not suitable for larval
therapy [7].
75.2.5 Surgical or Sharp
Debridement
Surgical debridement into viable tissue is the
most effective method of wound debridement. It
is a common practice to use surgical debridement
at the rst or second visits followed by enzymatic
or autolytic debridement [4]. This debridement is
performed in the operating room in general
regional or sedation anesthesia using surgical
instruments, such as scalpel, Goulian or Humby
knife. Pros of this procedure include possibility
of large tissue removal when required, readiness
to take tissue samples from different tissues, and
option to reconstruct the defect simultaneously.
In those easy to bleed situations, such as infection or wound with vascular structures exposed,
controlling hemorrhage and bleeding is feasible
and safe in the operation room setting. Surgical
debridement is valuable in identifying osteomyelitis. Infected bone appears soft and does not
bleed as much as healthy bone. Debridement of
infected bone should be performed until the bone
appears solid and bleeds until biopsied [1].
Cons of the procedure include special
resources, surgical specialist training with specic knowledge.
Conservative sharp wound debridement uses
curettage, scissors, or scalpel to remove only
nonviable tissue and wound debris (Fig.75.1).
Pros include conservative sharp wound debridement which can be performed at outpatient
clinic or bedside (Figs.75.2 and 75.3). Bleeding
after debridement can be controlled through
direct pressure, cauterization by silver nitrate,
electrocautery or by hemostatic agents such as
hydrogen peroxide, thrombin, or oxidized cellulose [1].
Hydrosurgery [8], a high-pressure, waterbased jet system for debridement was designed
for accurate debridement for preserving as much
as possible healthy tissues. However, despite the
intuitive advantages, the use of a hydrosurgery
system has been recommended for tangential
excision in burns or large wounds with a thin
layer of nonviable tissue [9]. Cons are disposable
handpieces and tubing, thus increasing the carbon footprint.
Ultrasonic or ultrasound debridement is a
method of removing nonviable tissue through
microstreaming and cavitational effects [10].
Recent studies show that ultrasound may be a
real alternative for surgical debridement when a
patient is not t for anesthesia. Pros include that
ultrasound debridement can be performed in an
outpatient setting.
492
K. Isoherranen and V. Koljonen
Fig. 75.1 Instruments and agents needed for sharp debridement
Fig. 75.2 A non-healing, traumatic ulcer in a patient suf-
fering from rheumatoid arthritis
Fig. 75.3 The ulcer after local anesthesia, biopsy, and
sharp debridement with curettage
75 How toBecome anExpert inDebridement? Physician Perspective
75.3 When NOT toDebride?
In order to be skillful you need to recognize situations when surgical or other forms of debridement would worsen the healing process. When
the wound is covered by a dry, black eschar, it
does not have to be debrided in every case.
Ischemic wounds before vascular assessment and
intervention belong to this category. If the eschar
is rmly adherent, the patient is afebrile and there
is no drainage from the wound, the dry eschar
does not have to be removed [1]. Atypical wounds
in the active inammatory process are wounds
that worsen by sharp or surgical debridement [3].
Fig. 75.5 The Martorell ulcer after local anesthesia and
sharp debridement with curettage. Debridement continued with autolytic debridement
75.5 Pain Treatment During
75.4 Debridement inAtypical
Wounds
Expertise in debridement includes adequate analgeAtypical wounds need a specialized approach in
debridement (Figs. 75.4 and 75.5). Pyoderma
gangrenosum and vasculitic wounds exhibit
pathergy, i.e., worsening by trauma, and sharp
debridement leads to deterioration and enlarging
of the wound [3]. Recommended debridement
techniques in these wounds are autolytic and biologic treatment. The advantages of biologic treatment include specicity; maggots ingest only
dead tissue, not the viable one, and the pathergy
reaction is minimal. Conservative sharp and surgical debridement can be performed when
inammation has been reduced by an immunosuppressant, e.g., prednisolone, and this usually
takes 2–3weeks. The clinical evaluation of the
stage of the inammatory reaction needs training,
so the decision of the right timing of debridement
should be done by a trained dermatologist.
sia during treatment. Dead tissue does not feel pain,
and sometimes debridement can be performed fea-
sible without analgesia. However, many wound
types are very painful, and adequate analgesia must
be planned beforehand. Talking through the proce-
dure and explaining the efforts employed to mini-
mize pain, reduces the experienced pain. A skillful
physician uses “verbal” anesthesia frequently. If
systemic analgesics or topical local analgesics are
used, they should be applied 30–60 min before
debridement [1, 7]. As procedural pain can be very
intense, it is acceptable to go directly to opioids
(e.g., oxycodone) without following the three-step
approach to pain treatment recommended by
WHO.Adequate anesthesia can usually be achieved
through direct inltration of the anesthetic agent
locally into the wound bed. In this process, the nee-
dle is directed from healthy tissue to the wound bed
to avoid microbial contamination.
493
Debridement
75.5.1 The Future ofDebridement
Future aspects include imaging devices that could
determine the amount of tissue to be removed,
and the depth of debridement and one promising
technology is optical coherence tomography
[11]. There is also a clear need for technology
that assists the clinician in identifying viable tis-
sue from nonviable one [4, 12].Fig. 75.4 A Martorell hypertensive ulcer
494
K. Isoherranen and V. Koljonen
References
1. Steed DL.Debridement. Am J Surg. 2004;187:71S–4S.
2. Falabella AF. Debridement and wound bed preparation. Dermatol Ther. 2006;19:317–25.
3. Isoherranen K, O’Brien JJ, Barker J, Dissemond J,
Hafner J, GBE J, Kamarachev J, Läuchli S, Monetro
EC, Nobbe S, Sunderkötter C, Velasco ML.Atypical
wounds. Best clinical practice and challenges. J
Wound Care. 2019;28(Sup6):S1–S92.
4. Eriksson E, Liu PY, Schultz GS, Martins-Green
MM, Tanaka R, Weir D, Gould LJ, et al. Chronic
wounds: treatment consensus. Wound Rep Reg.
2022;30:156–71.
5. Schultz G, Bjarnsholt T, James GA, Leaper DJ,
McBain AJ, Malone M, etal. Consensus guidelines
for the identication and treatment of biolms in
chronic nonhealing wounds. Wound Repair Regen.
2017;25(5):744–57.
6. Malone M, Schultz G. Challenges in the diagnosis
and management of wound infection. Br J Dermatol.
2022:1–8.
7. Strohal R, Dissemond J, O’Brien JJ, Piaggesi A,
Rimdeika R, Young T, Apelqvist J.EWMA document:
debridement. An updated overview and clarication
of the principle role of debridement; 2013
8. Ferrer-Sola M, Sureda-Vidal H, Altimiras-Roset
J, Fontsere-Candell E, Gonzalez-Martinez V,
Espaulella-Panicot J, etal. Hydrosurgery as a safe and
efcient debridement method in a clinical wound unit.
J Wound Care. 2017;26(10):593–9.
9. Hurd T, Kirsner RS, Sancho-Insenser JJ, Fumarola S,
Garten A, Patel M, etal. International consensus panel
recommendations for the optimization of traditional
and single-use negative pressure wound therapy in
the treatment of acute and chronic wounds. Wounds.
2021;33(suppl 2):S1–S11.
10. Flores-Escobar S, Alvaro-Afonso FJ, Garcia-Alvarez
Y, Lopez-Moral M, Lazaro-Martinez JL, GarciaMorales E. Ultrasound-Assisted Wound (UAW)
debridement in the treatment of diabetic foot ulcer:
a systematic review and meta-analysis. J Clin Med.
2022;11(7):1911.
11. Tsai M-T, Yang C-H, Shen S-C, Lee Y-J, Chang F-Y,
Feng C-S. Monitoring of wound healing process of
human skin after fractional laser treatments with optical coherence tomography. Biomed. Opt Express.
2013;4(11):2362–75.
12. Falanga V, Brem H, Ennis WJ, Wolcott R, Gould
LJ, Ayello EA. Maintenance debridement in the
treatment of difcult-hard-to-heal chronic wounds.
Recommendations of an expert panel. Ostomy Wound
Manage. 2008;(Suppl):2–13.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License (http://creativecommons.org/licenses/by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit
to the original author(s) and the source, provide a link to the Creative Commons license and indicate if you modied the
licensed material. You do not have permission under this license to share adapted material derived from this chapter or
parts of it.
The images or other third party material in this chapter are included in the chapter's Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
Regulations forConservative
Sharp Debridement forNurses
inEurope
SebastianProbst
76
76.1 Introduction
In Europe, different levels of nursing educations
with a different level of competences exist. The
RN4CAST, for example, demonstrates how vast the
nursing education as well as their conditions of service, their regulations and policies within Europe
are [1]. The report demonstrates that each European
country has their own denitions, regulations, and
policies about the nursing profession. This can, in
clinical practice, easily lead to confusion. As a result
of this confusion, specialized knowledge, skills, and
competencies are required to initiate, direct, and
perform safe and effective debridement [2]. These
skills have to be acquired during the nursing education and have to be practiced in different workshops
and in clinical practice.
When performing wound debridement, nurses
should always work within their scope of practice
and local policy and procedures [3, 4]. This chapter will overview regulations for sharp debridement for nurses in Europe and will show when to
debride and what are the requirements of nurses
to debride a wound.
S. Probst (*)
HES-SO University of Applied Sciences and Arts
Western Switzerland, Geneva, Switzerland
University Hospital Geneva, Geneva, Switzerland
University of Geneva, Geneva, Switzerland
University of Galway, Galway, Ireland
Monash University, Melbourne, Australia
e-mail: sebastian.probst@hesge.ch
76.2 Regulations forConservative
Sharp Debridement
forNurses inEurope
Performing a bed-side conservative sharp
debridement may be independently restricted
either by safety factors regarding the physical
setting or by the legislation that governs a health
care sector. In most European countries, it is a
physician delegated task. However, conducting a
debridement by a nurse in clinical practice
requires a certain level of education. For example, the Ashford and St. Peter Hospital in the UK
[5] require that only registered nurse with a
wound care specializations having completed an
education program in wound debridement, that
includes conservative sharp debridement, recognized by a University and at a minimum of level
6 and/or endorsed and approved by the European
Wound Management Association [6]. Initial and
continued competency shall be required and documented for all registered nurse with a wound
care specializations performing debridement.
Competency is not only a skill demonstration,
but also includes assessment contributing to a
nursing diagnosis with the development and
application of a plan of care, evaluation, and reassessment. The registered nurse performing
wound debridement ensures that an assessment
of the total patient care requirements before, during, and after wound debridement has been completed by a registered nurse. The registered nurse
has to recognize potential complications of
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_76
495