wound debridement and if so has to apply univer­sal precautions and other measures to prevent bleeding or infection and contamination.

processes?

• Is there any pain medication prescribed target­ing the nociceptive and/or the neuropathic pain?

• Is it necessary and what form should it take?

• Stop the procedure when the anatomy of the wound and surrounding area is unclear or a structure cannot be identied or bleeding is excessive or the source is unclear.

There is a growing body of evidence and agree­ment among wound clinicians and scientists that debridement represents a necessary process in reducing bacteria, infection, and a biolm within a wound and promotes a stimulatory environ­ment for healing [1]. The selection of a debride­ment method should be based on the clinical context, goals of care, the clinician’s expertise, and local resources. Despite the fact that the cost savings demonstrated when conservative sharp debridement (CSD) is part of a best practice plan of care for wounds, many community nursing agencies are not able to provide CSD as part of their care delivery, or they may not be aware of what their nurses are doing [2]. As a result of this confusion, specialized knowledge, skills, and competencies are required to initiate, direct, and perform safe and effective debridement [3]. When performing wound debridement, clini­cians should always work within their scope of practice and local policies and procedures [1, 4]. This chapter will briey overview regulations for CSD for nurses in North America after review

The notion of danger to the patient for debride­ment is more with CSD that nurses should pos­sess, and too often, the dangers of this type of debridement are confused with the dangers of surgical sharp debridement made by physicians. But this danger is poorly dened in the literature. This danger can often be associated with failure to assess the arterial blood ow of the wound prior to debridement as stated by national and international guidelines [7–9] and failure to rec­ognize the anatomy of the tissue, where wet

necrosis may be mistaken for tendon and the liga­ments, for example, or exaggerated depth of con­tact with bone that can lead to osteitis (Figs.77.2 and 77.3).

ment requiring adequate pain management, simi­lar to post-operative nursing care [6]. The main quality of these two types of surgical debride­ment is the rapid removal of necrotic tissue and microorganisms from the wound bed [1]. It is known that one primary justication to use the rapidity of CSD is that the evidence that biolms can reside deep within the extracellular matrix of the slough, debris, necrotic, and other tissues pro­vides a rationale for removing non-viable tissue via rapid debridement methods to reduce them [1, 13]. For the other types of debridement, with­out any education, the nurses are already doing them as, for example: a nurse who uses an inter­active dressing such as a hydrober or alginate or a product such as a cadexomer proceeds with an autolytic debridement. If a nurse uses a dry dress­ing such as a cotton pad on a granulation wound bed, she will perform a mechanical wet-to-dry debridement (mechanical) and nally, if she uses a wound cleaning pressure greater than 15psi for irrigation, she does mechanical debridement. Is these three type of debridement are so much harmful for the patient? It will be important in the future to distinguish between the types of debridement and their associated risks before developing specialized debridement courses so as not to delay the transfer of knowledge into practice. Rather, it is important to emphasize the contraindications to initiating any debridement, i.e., poor blood ow to the wound.

Unfortunately, even legislation framing nurses’ clinical practice does not consider the specics of the types of debridement that can contribute to harm in patients when it is well doc­umented that necrotic tissue left in place in a wound bed with healing potential can easily lead to wound infection by inhibiting oxygen delivery [1].

In Canada, the provincial/territorial govern­ments delegate the power to regulate all catego­ries of nurses to the provincial/territorial nursing regulatory bodies [5]. Each provincial or territo­rial regulatory body for nursing in Canada has an individual scope of practice, too [4, 5]. Some allow the performance of CSD provided the nurse has the knowledge, skill, and judgment necessary to assess the individual situation for risks and benets [4]. Some do not. NSWOCC published in 2021 the results of a scoping review to edit the

Debridement: Canadian best practices recom- mendations for nurses. This document can be

found on the website https://www.nswoc.ca/

bpr?lang=fr. This document further informs the

They add that each employer has the ability to restrict further a nurse’s ability to perform an act, and ultimately, the nurse is accountable for ensur­ing they possess the knowledge, skills, judgment, experience, and authorization before initiating or performing debridement [5]. However, other reg­ulations in each province may prevent nurses from performing CSD even when the college of nurses allows it [4]. For example, some hospital and long-term care acts may prevent a nurse from performing CSD in their employing organization without a medical delegation or transfer of func­tion [4]. Even in those employment situations where CSD by nurses is allowed, high-level sup­port and clear organizational policies and proce­dures that outline the educational and practice requirements for anyone performing CSD must be present [4].

therapists [20]. But the problem remains the same, namely that the regulations on debride­ment are on all types of debridement. Even if no education program exists, the nurses still pro­mote autolytic, mechanic, and chemically debridement by, respectively, using interactive dressing, irrigation cleaning and cadexomer without using scalpel, scissors, and pliers.

tional institutions in nursing will have to intro­duce the notions of all types of debridement in the teaching in theoretical and practical way, emphasizing CSD for the safety of the patient and to avoid all infections and biolms in chronic wounds. Regulations may change in time, so the nurse who wants to practice CSD is responsible for contacting the individual state practice act before performing this procedure (Tomaselli,

• Education, knowledge, technical skills, expe­rience, critical thinking, and judgment have to go in the same way as debridement regula­tions for the healing wound process for the best quality of life for our patients.