Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Local Wound Care - Debridement
Recommendation Level of Evidence
3.2a  Lower extremity ulcers or wounds in patients who are gravely palliative with dry eschar need not be debrided if they do not have edema, erythema, fluctuance or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement. IV
3.2b  Prior to debridement on ulcers on the lower extremities, complete a vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) to rule out vascular compromise. IV
3.2c  Determine if debridement is appropriate for the patient and the wound. IV
3.2d  If debridement is indicated, select the appropriate method of debridement considering: Level of Evidence IV
  • Goals of treatment (e.g., healability);
  • Client´s condition (e.g., end of life, pain, risk of bleeding, patient preference, etc.);
  • Type, quantity and location of necrotic tissue;
  • The depth and amount of drainage; and
  • Availability of resources.
IV
3.2e  Sharp debridement should be selected when the need is urgent, such as with advancing cellulitis or sepsis, increased pain, exudate and odour. Sharp debridement must be conducted by a qualified person. IV
3.2f  Use sterile instruments to debride pressure ulcers. IV
3.2g  Prevent or manage pain associated with debridement. Consult with a member of the healthcare team with expertise in pain management. Refer to the RNAO Best Practice Guideline Assessment and Management of Pain (Revised) (2007). IV

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