Sharp debridement bedside. Debridement with patient under anesthesia operating room. Autolytic debridement. Chemical or enzymatic debridement.
Mechanical debridement. Biologic debridement. But as debridement occurs, slough will naturally liquify causing clinicians to incorrectly document this as purulent drainage. An easy way to determine if the wound is still exhibiting signs of slough and not purulence is the odor.
An easy way to identify the signs and symptoms of purulence infection are:. Redness that does not improve with elevation of affected limb. Determining if a wound bed is plagued with slough, purulence, or sometimes both can be challenging but cleansing the wound bed thoroughly before making any observations or conclusions will help to differentiate which wound type you are encountering. Slough will always show signs of stringy textures, yellow coloring, and will be more granular after cleansing.
Purulence will always emit an odor after cleansing and will show signs of infection and erythema. When in doubt, consult with the Cork Medical wound care team for further evaluation. A wound typically cannot heal if either infection or slough is present, but the treatment plan for each is very different. Taking a multidisciplinary approach and managing the entire patient are critical to wound healing. Accurate documentation is essential in painting a picture of that wound for different team members who may be reviewing the medical record to determine their plan of care.
Always ask—there's something new to learn every day! About the Author Holly is a board-certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio.
She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing.
Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation.
She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc.
Chronic wounds and their management pose a serious challenge to clinicians worldwide and are one of the major public health challenges faced by developing countries. Worldwide, over 40 million people develop chronic wounds With that in mind, our evidence-based tool needs to be used correctly to yield accurate results. Working with long-term The subject of my previous blog on skin assessment was interview; here in part 2, we will look at the elements of observation.
Interviewing clients and significant others can provide the clinician with valuable information related to the View the discussion thread. Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website "Content" are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
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By Holly M. Tissue Type: Slough We've all heard about slough… most of us have seen it, debrided it, and even watched it change from wet stringy, moist, yellow to dry eschar thick, leathery, black. So we refer to our wound care "tool box" and develop the best plan of attack: Sharp debridement bedside Debridement with the patient under anesthesia operating room Autolytic debridement Chemical or enzymatic debridement Mechanical debridement Biological debridement Once we initiate our plan of care usually from the choices listed above , debridement will begin to occur or will occur at the point of treatment with sharp debridement in the operating room or at the bedside, if appropriate.
Purulence and Infection Is the drainage liquefied slough or truly purulence? Erythema Odor Redness that does not improve with elevation in a limb not dependent rubor Pain Increase in drainage color: green or blue, etc. Fever, chills, nausea, vomiting systemic Does your patient have signs or symptoms of infection, along with purulence?
Here are some additional tips for when you're not sure of what you see or what to document: Always cleanse the wound before documenting odor. If you're not sure what it is, don't document it yet— check first keep in mind that slough can be confused with purulence, tendon, or other underlying structures. If something doesn't look right to you, it probably isn't—trust yourself, and notify appropriate team members. If what you're cleansing out of the wound is stringy and yellow, and the wound base appears more granular after cleansing, it is most likely slough.
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