Med/Surg I, Module 4 Part 1 of 4

Med/Surg I, Module 4 Part 1 of 4
Orthopedic System Alteration in Mobility Integumentary System

Chronic Musculoskeletal Conditions
Curvature of the Spine Osteoporosis Osteomyelitis Osteoarthritis

Curvature of the Spine Kyphosis (left) and Lordosis (right) Kyphosis
Manifestations Loss of bone mass related to aging Loss of height with progressive spine curvature, low back pain Kyphosis (“dowager’s hump”) and cervical lordosis Increased bone fragility Increased risk of fractures of forearm, spine, hip Kyphosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center. Lordosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.

Source: Wikimedia Commons, Public Domain
Scoliosis Source: Wikimedia Commons, Public Domain

Osteoporosis Increased Risk Family history Female
Menopause-related low estrogen females, low testosterone males Medications Lifestyle Family history, especially small frame Asians & white females Female Menopause-related low estrogen females, low testosterone males Use of anticonvulsants, corticosteroids, heparin, tetracycline, thyroid supplements Lifestyle: inactive, cigarette &/or alcohol use, low lifetime calcium intake

Osteoporosis Prevention Diet Calcium supplements Stop smoking
Alcohol and caffeine intake weight-bearing exercise Sunlight Increase dietary calcium & vitamin D: milk & milk products best sources; sardines, clams, oysters, salmon, dark green leafy vegetables Teach calcium in diet: Calcium supplements post menopause Stop smoking Decrease alcohol and caffeine intake Increase weight-bearing exercise: at least 30 minutes 3 times per week Increased exposure to sunlight: vitamin D increases calcium absorption in intestine

Osteoporosis Diagnosis Dual-energy x-ray absorptiometry (DEXA) scan
Qualitative ultrasound (QUS) of heel or calcaneus Diagnosis Dual-energy x-ray absorptiometry (DEXA) scan measures bone mineral density in hip, wrist or vertebrae: best tool Qualitative ultrasound (QUS) of heel or calcaneus: low cost screening tool

Osteoporosis Collaborative Management Replace estrogen or testosterone
Raloxifene (Evista) Biphosphonates: Alendronate (Fosamax) and risedronate (Actonel) Teriparatide (Forteo) Ibandronate sodium (Boniva) Calcitonin (Miacalcin) Sodium fluoride Collaborative Management: retard bone resorption: Replace estrogen after menopause or Raloxifene (Evista): mimicks estrogen effect on bones without risks of estrogen Biphosphonates: Alendronate (Fosamax) and risedronate (Actonel) inhibit bone resorption Teriparatide (Forteo): synthetic parathyroid increases new bone formation Ibandronate sodium (Boniva): both prevents bone loss & increases bone density Calcitonin (Miacalcin): increases bone formation, decreases resorption Sodium fluoride stimulates bone formation

Osteoporosis Nursing Care Prevent falls Treat pain Orthotic devices
Refer to physical therapy Range of motion exercises Nursing Care Prevent falls: use assistive devices prn Treat pain: nonsteroidal anti-inflammatory drugs (NSAIDS) Orthotic devices to support spine Refer to physical therapy to strengthen abdominal and back muscles Range of motion exercises to maintain joint mobility

Osteomyelitis Local swelling Redness Tenderness Pain Fever Bone pain
Clinical Manifestations Local swelling, redness, tenderness, pain Fever Bone pain: constant, localized, pulsating; intensifies with movement Source: UCSD Catalog of Clinical Images, Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California,

Diagnosis Bone scan Biopsy
MRI, CT or ultrasound: fluid collection, abscess, periosteal thickening Elevated WBC, positive blood cultures Diagnosis Bone scan Biopsy MRI, CT or ultrasound: fluid collection, abscess, periosteal thickening Elevated WBC, positive blood cultures

Collaborative Care Surgical debridement is the primary treatment
Postoperative care: wound irrigation with strict sterile technique; monitor site for signs of infection, monitor temperature and WBC Most cases caused by Staphylococcus aureus: Parenteral antibiotics based on wound, blood cultures for 4-6 weeks or Oral twice-daily ciprofloxacin if chronic Hyperbaric oxygen therapy to promote healing Collaborative Care Surgical debridement is the primary treatment Postoperative care: wound irrigation with strict sterile technique; monitor site for signs of infection, monitor temperature and WBC Most cases caused by Staphylococcus aureus: Parenteral antibiotics based on wound, blood cultures for 4-6 weeks or Oral twice-daily ciprofloxacin if chronic Hyperbaric oxygen therapy to promote healing

Osteoarthritis Osteoarthritis, formerly called degenerative joint disease (DJD), is the most common joint disorder. Intra-joint cartilage erodes over time leading to synovitis (inflammation) and subluxation (joint dislocation) and joint deformities. This leads to marked immobility, pain, muscle spasm and inflammation. Reprinted with permission: Charles J. Eaton, M.D. of The Hand Center Reprinted with permission: DePuy Orthopaedics, Inc.

Clinical Manifestations
Crepitus Joint stiffness Pain with movement Heberden’s nodes (distal joints) and Bouchard’s nodes (proximal joints) Knees: Joint effusions Muscle atrophy Spine: radiating pain, stiffness, muscle spasms in extremities Hips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotation Clinical Manifestations Crepitus: grating sensation as joint moves Joint stiffness following inactivity that decreases with a few minutes of movement Pain with movement, relieved by resting the joint Hands: Heberden’s nodes (distal joints) and Bouchard’s nodes (proximal joints) (see above) Knees: Joint effusions (fluid collection under patella) Muscle atrophy around affected joint from disuse Spine: radiating pain, stiffness, muscle spasms in extremities Hips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotation

Collaborative Care Analgesics Rest Heat Weight control TENS
Pain Relief: Analgesics: topical salicylates (Aspercreme), topical capsaicin (burning sensation- wear gloves, wash hands immediately), non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections into joint, muscle relaxants for spasm Rest: splint or brace - balance rest and activity to maintain mobility; adequate sleep at night + nap Positioning: place joints in functional position, small neck pillow but avoid other pillows to prevent flexion contractures; use proper posture Heat: hot showers and baths, hot packs or compresses, moist heating pads, paraffin dips, diathermy (electrical current), ultrasound therapy (sound waves) Weight control: well-balanced diet with gradual weight loss will decrease stress on weight-bearing joints, slow degeneration Transcutaneous electrical nerve stimulation (TENS): Transmission of low-voltage electrical impulses from a handheld battery-powered generator to the skin via surface electrodes.

Total Joint Arthroplasty
Source: Hughston Foundation Source: Hughston Foundation

Postoperative Care Abduction pillow, neutral position Prevent embolus
Prevent infection Assess for bleeding Neurovascular compromise Manage pain Promote activity Postoperative care: Prevent joint dislocation (subluxation) Abduction pillow, leg in neutral rotation Watch for dislocation (pain, shortening, leg rotation) Prevent thromboembolism Compression stockings, pumps Anticoagulants Leg exercises Prevent infection Monitor incision, check drainage Check temperature, WBCs Assess for bleeding Blood salvage, reinfusion up to 4 hours Monitor dressing, drains Epoetin alfa (Epogen) Assess for neurovascular compromise Color, sensation, movement (CSM), compare with opposite leg Local temperature, distal pulses, capillary refill Manage pain Patient-controlled analgesia (PCA) Bupivacaine (Marcaine) pump directly into surgical site Promote activity Ambulate day after surgery Raised toilet seat (no flexion beyond 90 degrees) Straight-back chair, walker, physical therapy Partial weight bearing if prosthesis uncemented

Total Knee Arthroplasty
Continuous passive motion (CPM) device Ice or hot/ice machine Keep knee in neutral, no rotation inward or outward Monitor: thromboembolism, infection, bleeding, CSM Teach: no hyperflexion or kneeling for 6 weeks Total Knee Arthroplasty Continuous passive motion (CPM) device: keeps knee in motion, prevents scar tissue Set for degrees of range and number of cycles/minute Intermittent for several hours Check padding, postioning in machine Ice or hot/ice machine Keep knee in neutral, no rotation inward or outward Monitor: thromboembolism, infection, bleeding, CSM Teach: no hyperflexion or kneeling for 6 weeks

Acute Musculoskeletal conditions: FRACTURES
Source: Wikimedia Commons/Creative Commons Licence Phote courtesy of “Mexican 2000”/Flickr

Open or Closed? Closed – No break in the skin
Open (also called “Compound”) Complete - Entire width of bone broken, divided into 2 sections Incomplete - Break is through only part of the bone; also called “Greenstick” Comminuted – Several bone fragments Photo source: American Academy of Orthopaedic Surgeons,

Compound Fractures Grade I Grade II Grade III Small wound
~1 cm to 10 cm skin & muscle contusions Grade III Large Damaged skin, muscle, nerves, vessels Grade I: Clean wound, less than 1 cm long Grade II: Larger wound, skin and muscle contusions, no extensive soft tissue damage Grade III: Wound larger than 1 cm, highly contaminated, damage to skin, muscle, nerve tissue and blood vessels extensive soft tissue damage

Assessment Can he move it? Does it hurt? Is it deformed? Deformity
Local edema, ecchymosis Pain/tenderness Crepitus Ecchymosis Emergency Care Immobilize: splint joint above through joint below fracture Tissue perfusion: Apply direct pressure to control bleeding, assess distal pulses Prevent infection: Cover open wounds with sterile dressing

Key Treatments Closed reduction Immobilization Open reduction Splint
Cast Open reduction Closed reduction: Manual traction applied to move bones back together, then casted to maintain position. Done under anesthesia (could be conscious sedation in ER); will reduce pain and muscle spasm. Open reduction involves rods, plates, screws followed by casting in O.R. Open reduction; External Fixation National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center

Cast Care Prevent indentations when wet Elevate uniformly Air dry
CSM – What am I looking for? No scratching implements! Cast Care Prevent indentations when wet: Handle wet cast with palms, use pillows length-wise to maintain even pressure – cover pillows with towels to promote drying; Elevate uniformly: turn patient/cast to expose all wet areas to air. Air dry Color, Sensation, Movement (CSM): Assess q 15 minutes x 4 hours, then q 1 hour until 24 hours post casting Teach: No scratching implements

Skin Traction To decrease muscle spasm
Weight 5-7 pounds attached w/ adhesive tape Used before surgical repair Check sling, tape for placement Keep pulley, weights in place Skin Traction To decrease muscle spasm Five-to seven-pound weights attached to the skin to indirectly apply pulling force on the bone. If traction is temporary, or if only a light or discontinuous force is needed, then skin traction is the preferred treatment. Because the procedure is not invasive, it is usually performed in a hospital bed. Weight 5-7 pounds attached w/ adhesive tape Weights are attached either through adhesive or nonadhesive tape, or with straps, boots, or cuffs. Keep the straps or tape loose enough to prevent swelling and allow good circulation to the part of the limb beyond the spot where the traction is applied. The amount of weight that can be applied through skin traction is limited because excessive weight will irritate the skin and cause it to slough off. Used before surgical repair Make sure the limb stays aligned, skin care so it does not become sore and irritated. The patient should also be alert to any swelling or tingling in the limb that would suggest that the limb has been wrapped too tightly. Check sling, tape for placement Keep pulley, weights in place Photo Source: Royal College of Surgeons of Ireland (RCSI), Creative Commons

Buck’s Traction Hip fracture assessment What to do immediately?
Buck’s traction assessments What should be done later? What teaching is needed? Buck’s: NURSING, Nov 2003 by Sprauve, Doylean AGNES HIGHTOWER, 85, is brought to your ED after falling onto her right hip. She's alert and oriented and appears well nourished. She says she now has severe pain in her right hip and can't move it. What's the situation? Ms. Hightower's right leg is externally rotated and appears shorter than the left one. Her right posterior tibial and dorsalis pedis pulses are +2. Her right leg is cool to touch with limited range of motion. Her left leg is normal. An X-ray of the right hip reveals an intertrochanteric fracture (a fracture between the greater and lesser trochanter of the femur). No osteoporotic changes to the bone are seen on X-ray. The primary care provider calls for an orthopedic consultation. What's your assessment? Ms. Hightowers fracture needs to be treated promptly to avoid tissue necrosis, blood loss, and infection. Pain management is also a priority. What must you do immediately? Start an I.V. line for fluids and keep Ms. Hightower N.P.O. before surgery. Administer parenteral analgesics as prescribed and a muscle relaxant if prescribed. Monitor her vital signs and level of consciousness frequently, watching for respiratory depression and signs of shock, such as decreases in level of consciousness and urine output. To stabilize the fracture, Ms. Hightower s right leg is placed in Buck's traction, which includes a foam boot. A weight attached to the boot pulls the bone fragments into alignment. Buck's traction prevents further traumatic injury and reduces muscle spasms. However, traction puts a patient (especially an elderly one) at increased risk for complications of immobility, including skin breakdown, deep vein thrombosis (DVT), pulmonary embolism (PE), and pneumonia. Assess Ms. Hightower's skin every 2 hours. Place her on a pressure-reducing mattress and provide an overhead trapeze bar to help her with bed mobility. Monitor leg sensation and movement every 2 hours; the traction weights put pressure on her peroneal and tibial nerves. Regularly assess her feet and legs for pain, temperature, pulses, capillary refill, color, and edema. Apply compression stockings to promote venous return and reduce the risk of DVT and PE. Obtain preoperative lab studies and prepare Ms. Hightower for surgery. Although she has fewer reserves than a younger patient, she has no preexisting medical conditions, so her prognosis for successful surgery and functional recovery is good. Twenty-four hours after her fall, Ms. Hightower undergoes a successful open reduction and internal fixation of her right hip. What should be done later? After surgery, Ms. Hightower is transferred to the orthopedic unit, where she'll be monitored for complications such as hemorrhagic shock, neurovascular impairment, and fat embolism (a risk in patients with long bone fractures). The primary care provider orders low-molecular-weight heparin to prevent DVT and PE. Manage Ms. Hightower's pain, encourage early ambulation and good nutrition, and maintain her fluid balance. Monitor the amount and character of drainage from the surgical site and her intake and output, assess her vital signs, and monitor hemoglobin and hematocrit levels. She'll have I.V. fluids and a patient-controlled analgesia pump. Ms. Hightower will have a risk assessment for falls, so that the cause of her fall (for example, overmedication) can be determined and she can be educated about fall prevention. Buck’s Traction Source: DeRoyal Patient Care

Other Skin Traction Russell’s Cervical Thomas splint Bryant’s Pelvic
Russell's Traction: Traction composed of Buck's extension on the lower leg. Cervical Traction: Traction applied to the neck by use of a head halter. Thomas Splint: A full leg splint used mostly in emergency transport situations. Bryant's Traction: Traction using vertical suspension of the legs. The child's pelvis is elevated off of the bed.

Skeletal Traction Weight 25-40 pounds Are the ropes on the pulleys?
Are the weights hanging free? Where are the knots? Monitor CSM Pin care? Skin care Skeletal Traction Skeletal traction may be configured in two ways: straight/running traction or balanced suspension traction. In straight or running traction the counterforce is supplied by the patient’s body with the bed in one of these positions: 1) flat; 2) tilted away from the traction pull (place bed in Trendelenburg/reverse Trendelenburg position); or 3) with the head of the bed elevated and/or knee catch. The purposes of traction are to: reduce fractures or dislocations maintain body or limb alignment decrease muscle spasms and relieve pain correct, lessen or prevent musculoskeletal deformity promote rest of an injured or diseased part promote exercise Nursing Management Weight pounds Are the ropes on the pulleys? Are the weights hanging free? Where are the knots? (should not be on pulleys) Monitor CSM Pin care Skin care

Balanced Suspension Counter-traction by weights
Check ropes, knots, weights Are traction bars tightened? Is patient in alignment? How do pin sites look? When can I remove weights? In balanced suspension traction, slings or splints are used to support the affected part. Although the body provides some countertraction, further countertraction is achieved by additional balanced weights attached to the overhead frame. These keep a pull directly opposite and equal to the traction force pull. Assess traction apparatus effectiveness every 8 hours by ensuring that: • ropes are on center of pulley track and are not frayed; knots are secured • weights are hanging freely, away from bed and not touching floor •spreader bars, foot plate, or splints do not touch foot of bed • overhead frame/ traction bars are tightly fastened Assess for correct positioning of traction and alignment of affected extremity and alignment of entire body every shift. Assess muscle strength, range of motion and ability to perform ADL’s every shift. Assess pin sites/open wounds every 8 hours for: • skin tenting (ensure skin is not attached to pin) • signs and symptoms of infection • persistent erythema or skin breakdown • bleeding • skin tension • drainage REPORTABLE CONDITIONS/ Notify MD for: •diminution of neurovascular status •tenting, erythema, bleeding, or serous/purulent drainage around pin sites •severe pain/ muscle spasms unrelieved by medication and/or repositioning •persistent erythema or skin breakdown in areas other than pin sites •disruption of traction •skin coolness or mottling in affected extremity Attach an overhead frame with trapeze to facilitate patient mobility and independence. Encourage patient to perform ROM exercises of unaffected extremities and unaffected joints of extremity in traction (maintaining body extremity alignment) every two hours while awake. Encourage dorsi-/plantar flexion of feet and ankle circumduction exercises every 2 hours while awake. TRANSPORT: Maintain traction at all times. SAFETY: Do not remove or add weights to skeletal traction without physician’s order. Never take patient out of traction without a physician’s order.

Spinal Traction Where are the knots? Are the weights hanging free?
What do the pin sites look like? How do I turn the patient? How can I make the patient comfortable? - Turn patient by using logrolling technique (or use Stryker Frame, Circolectric bed, Roto Rest bed) - Maintain body alignment when in side position with full-length bath blanket roll and pillow between knees - Obtain prism glasses by initiating referral to Occupational Therapy. - Align the patient’s body with the pull of the traction - Position head properly to maintain countertraction - Reposition every 2 hours unless medically contraindicated.

Complications Compartment syndrome Fat embolism DVT Osteomyelitis
Aseptic necrosis

Compartment Syndrome Prevention Emergency care Check CSM Ice, elevate
Loosen dressing, open cast Emergency care Fasciotomy: Compartment Syndrome: patient complains of pain, tingling, tightness, fullness in muscle, then numbness, cell death Prevention Check CSM Ice, elevate Loosen dressing, open cast Emergency care Fasciotomy

Fat Embolism Long bones, multiple fractures Elderly: hip fractures
Altered mental status Respiratory distress Petechiae on trunk Prevention: early immobilization of fracture Fat Embolism Highest risk: Long bones, multiple fractures Elderly: hip fractures Signs and Symptoms: Altered mental status Respiratory distress Petechiae on trunk Prevention: early immobilization of fracture

Deep Venous Thrombosis
Most common complication Predisposing factors Common sites: leg, pelvic fx Pulmonary embolus prevention Deep Venous Thrombosis Most common complication Predisposing factors: Predisposing factors complicate the risk: obesity, smoker, heart disease, taking oral contraceptives or hormones, history of thromboembolic conditions Common sites: leg, pelvic fractures Prevention: Preventing a pulmonary embolus: mobilize unaffected extremities, assess legs for size variations, pain unrelieved by usual medication dosages. Deep Vein Thrombosis Source: National Heart & Blood Institute

Osteomyelitis Sources: open wounds, implanted hardware
Staphylococcus aureus usually Rx: IV antibiotics Osteomyelitis Sources: open wounds, implanted hardware Staphylococcus aureus usually Treatment: IV antibiotics Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including: People with diabetes Patients receiving hemodialysis People with weakened immune systems People with sickle cell disease Intravenous drug abusers The elderly Symptoms of osteomyelitis The symptoms of osteomyelitis can include: Pain and/or tenderness in the infected area Swelling and warmth in the infected area Fever Nausea, secondarily from being ill with infection General discomfort, uneasiness, or ill feeling Drainage of pus through the skin Additional symptoms that may be associated with this disease include: Excessive sweating Chills Lower back pain Swelling of the ankles, feet, and legs

Aseptic Necrosis Death of bone tissue
Hip fractures or bone displacement Hardware interferes with circulation Aseptic Necrosis Death of bone tissue Seen in: Hip fractures or bone displacement Hardware interferes with circulation

Amputation Diabetic, smoker, infected foot ulcer Trauma Grieving loss
Altered self concept Coping Family response Largest population: diabetic smoker with decreased peripheral circulation, develops foot ulcer, doesn’t inspect or treat it. Second largest population: young men taking risks, influence of chemicals Amputation Largest population: diabetic, smoker, infected foot ulcers Manage: Tissue perfusion: monitor skin flap CSM, Doppler pulse Pain: stump pain versus phantom limb Prevent infection: keep dressing intact, reinforce prn Promote ambulation: Trapeze, range of motion Flexion contractions (leg amputation): prone position q 3-4 hours, avoid pillows that flex hip or knee Prostheses: prosthetist-orthotist referral Wrap stump firmly with elastic bandages, figure-eight, reapply q 4-6 hours to reduce edema

Surgical Wounds Web Resource
Click tab titled, “Med-Surg 1” Drop down menu  choose “Wound Care” Risk Assessment mental status mobility activity nutrition/hydration circulation moisture exposure Assess patient's general status wound disrupts patient's entire life patient disease state that affects wound status wound etiology and type (acute vs. chronic)

Wound Assessment Measure the wound in centimeters
Assess phase of wound healing Reaction Regeneration Remodeling Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin Signs and symptoms of infection Drainage: amount, color, consistency, odor Wound Assessment Measure the wound in centimeters · Length (head to toe) X width (side to side) X depth Indicate deepest point using clock method (e.g. 6:00 5 cm) Depth cannot be accurately measured in the presence of necrotic tissue Measure depth and tunneling with a cotton swab Sketch wound in notes and place digital picture with date and time in chart Assess phase of wound healing Reaction Regeneration Remodeling Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin Signs and symptoms of infection Drainage: amount, color, consistency, odor

Wound Care Dressing The ideal dressing Keeps wound moist
Prevents maceration Protects from contamination Contains wound fluid Protects granulation tissue Wound Care Dressings Characteristics of an ideal dressing keep wound moist prevent maceration protect from contamination contain wound fluid protect granulation tissue

Traditional dry dressings
Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds Epithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time Nonocclusive: increased risk of contamination and infection Traditional dry dressings Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds during the inflammatory stage of healing decreased collagen production dermis is more fibroplastic, fibrotic and scarred Epithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time greater pain greater cost increased frequency of dressing changes (bid, tid, qid) Nonocclusive: increased risk of contamination and infection

Moist Wound Healing No eschar develops (crust, scab)
Enhances autolytic debridement: promotes role of macrophages and leukocytes Bacterial barriers: prevent wound contamination Wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing Moist wound healing Wound kept moist and protected from external environment no eschar develops (crust, scab) enhances autolytic debridement: promotes role of macrophages and leukocytes bacterial barriers: prevent wound contamination wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing Potential for infection Potential for increasing pathogen growth use carefully with immunocompromised patients occluded wounds show a shift from gram-positive to gram-negative organisms Signs of infection I-induration F-fever E-erythema E-edema Wound cultures need to be quantitative. Wound infection: > 105 colony forming units (CFU) of a specific pathogen per gram of tissue Accumulation of drainage Exudate: wound fluid containing dead cells, necrotic debris, liquefied eschar, growth factors, enzymes, etc. Drainage that is yellow in color and possesses an offensive odor is common with occlusive dressings (especially early when autolytic debridement is occurring) OSHA regulations state drainage must be contained: Maceration interferes with epithelialization General Principles Wounds generally get worse before they get better as ischemic tissue sloughs Odor often worsens Several methods need to be tried. Type of treatment changes during the course of healing. Primary goal of wound healing is to aid body's own healing mechanism Wounds can generally be treated based on appearance and drainage (scab) healing is slower

Potential for Infection
Signs of infection I-induration F-fever E-erythema E-edema Potential for infection Potential for increasing pathogen growth use carefully with immunocompromised patients occluded wounds show a shift from gram-positive to gram-negative organisms Signs of infection I-induration F-fever E-erythema E-edema Wound cultures need to be quantitative. Wound infection: > 105 colony forming units (CFU) of a specific pathogen per gram of tissue Accumulation of drainage Exudate: wound fluid containing dead cells, necrotic debris, liquefied eschar, growth factors, enzymes, etc. Drainage that is yellow in color and possesses an offensive odor is common with occlusive dressings (especially early when autolytic debridement is occurring) OSHA regulations state drainage must be contained: Maceration interferes with epithelialization General Principles Wounds generally get worse before they get better as ischemic tissue sloughs Odor often worsens Several methods need to be tried. Type of treatment changes during the course of healing. Primary goal of wound healing is to aid body's own healing mechanism Wounds can generally be treated based on appearance and drainage (scab) healing is slower

Absorptive powders and pastes
Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound Absorptive powders and pastes Usually starch copolymers or colloidal hydrophilic particles (cellulose, gelatin) Use: suer slurpers - used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound

Wound Healing Normal healing (3R's)
Reaction: inflammatory process (72 hours) Regeneration: proliferation (up to three weeks) Remodeling: (three weeks to two years) Wound Healing Normal healing (3R's) Reaction: inflammatory process (72 hours) Regeneration: proliferation (up to three weeks) Remodeling: (three weeks to two years)

Black Wound = Eschar Cellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissue If eschar becomes contaminated: becomes excellent medium for infection wound remains in reaction or inflammatory stage systemic signs of infection Eschar delays regeneration phase by interfering with cell migration and wound closure Risk of wound infection increases as the amount of necrotic tissue increases Needs debridement Black wound: most often in late reaction or early regeneration phase Macrophages are migrating to injury to clean up bacteria and debris Growth factors stimulating new vascular growth at wound base (angiogenesis), fibroblast migration and fibroblast proliferation Collagen being deposited, filling wound with scar tissue If eschar left intact and kept dry: cellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissue usually only inflamed around edges If eschar becomes contaminated: becomes excellent medium for infection wound remains in reaction or inflammatory stage systemic signs of infection Eschar delays regeneration phase by interfering with cell migration and wound closure Risk of wound infection increases as the amount of necrotic tissue increases Needs debridement

Yellow Wound Tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudate High risk of infection due to excellent medium for bacterial growth Needs continuing debridement Yellow wound (yellow necrosis or slough): tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudate Usually in late reaction or early regeneration High risk of infection due to excellent medium for bacterial growth Regeneration phase continuing with earlier wound contraction than with the thick eschar Needs continuing debridement Photo courtesy of Saddleback College, California,

Red Wound Red indicates presence of granulation tissue.
Color of granulation tissue affected by nutritional status and blood supply full thickness ulcer: crater with pale pink to beefy red granulation tissue crater slowly fills with granulation tissue from bottom upward Wound contraction and epithelialization continues. Epithelialization occurs from wound edges inward. Red wound: if chronic usually in late regeneration or remodeling phase. Red indicates presence of granulation tissue. Color of granulation tissue affected by nutritional status and blood supply full thickness ulcer: crater with pale pink to beefy red granulation tissue crater slowly fills with granulation tissue from bottom upward Wound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.

Wound Drainage Devices
Decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing). Examples: Penrose drain, Jackson-Pratt & Hemovac suction devices Wound Drainage Devices These devices decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing). Examples: Penrose drain, Jackson-Pratt & Hemovac suction devices

Dehiscence/Evisceration
Partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids. Dehiscence/Evisceration Wound dehiscence is a partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids. This is most likely to occur between day 5 and day 10 after surgery.

Bacterial skin infections
Folliculitis, furuncles, cellulitis: these infections are usually caused by Staphylococcus aureus. Folliculitis involves the hair follicle. Furuncles (boils) are deeper. Cellulitis is a general infection and involves deeper connective tissue. Topical antibiotics: Neomycin sulfate (Neosporin) Teach: wash area daily with antibacterial soap, allow skin to dry, prevent cross contamination Common Skin Infections Bacterial skin infections: Folliculitis, furuncles, cellulitis: these infections are usually caused by Staphylococcus aureus. Folliculitis involves the hair follicle. Furuncles (boils) are deeper. Cellulitis is a general infection and involves deeper connective tissue. Topical antibiotics: Neomycin sulfate (Neosporin) Teach: wash area daily with antibacterial soap, allow skin to dry, prevent cross contamination

Herpes Simplex Virus Type 1 causes common cold sore, type 2 causes genital herpes. After first infection, recurrence is triggered by stress. Spreads by direct contact. Patient is contagious for the first 3-5 days. Topical acyclovir (Zovirax) shortens the period of infection Herpes Simplex Virus (HSV): type 1 causes common cold sore, type 2 causes genital herpes. After first infection, recurrence is triggered by stress. Spreads by direct contact. The patient is contagious for the first 3-5 days. Topical acyclovir (Zovirax) shortens the period of infection

Herpes Zoster (Shingles)
Caused by reactivation of varicella (chickenpox). Occurs in the dermatome corresponding to the infected nerve. Eruptions follow several days after pain in the area, last several weeks. Acyclovir (Zovirax), given topically and/or orally controls the severity of the lesions and decreases pain. Herpes Zoster (Shingles): Caused by reactivation of varicella (chickenpox). Occurs in the dermatome corresponding to the infected nerve. Eruptions follow several days after pain in the area, last several weeks. Acyclovir (Zovirax), given topically and/or orally controls the severity of the lesions and decreases pain.

Acute Burns

Superficial Sunburn Epidermis pink to red Mild edema Painful
Healing time: 3-5 days No skin graft

Partial Thickness Burn
Brief contact: scald, flames, grease, chemicals Epidermis and dermis damaged Blisters if mild burn, pale, mottled, waxy white with deeper Painful Healing time: 2-6 weeks No grafting unless healing prolonged

Full Thickness Burn Prolonged contact: scald, flame, tar, grease, chemical, electricity Epidermis, dermis & underlying tissues damaged Waxy white, dry, leathery, charred No pain Healing: Weeks to months Skin grafts required

Percentage of Burn Injury
Rule of Nine: This formula divides the body into parts considered to be 9% (arms, head) to 18% (legs, front, back) of total body skin surface in adults. The small child has a different surface area breakdown. The burn size (as % of total) can then be used in the resuscitation formula. Source: Burn diagrams courtesy of BioTel Emergency Medical Service (EMS), Texas Department of Health,

Emergency Management Excessive leakage of plasma, especially in the first eight hours post-burn, causes hypovolemia, hypoproteinemia, hemoconcentration, electrolyte imbalances and acid base disturbances. In the absence of prompt fluid replacement, burn shock is imminent. Emergency Management In burns greater than 30% BSA, a generalized capillary permeability occurs due to systemic hypoproteinemia and inflammatory mediators, resulting in edema formation in non-burned tissues as well. Excessive leakage of plasma, especially in the first eight hours post-burn, causes hypovolemia, hypoproteinemia, hemoconcentration, electrolyte imbalances and acid base disturbances. Plasma volume is reduced by as much as 23-27%, with a reduction in cardiac output and an increase in peripheral vascular resistance. In the absence of prompt fluid replacement, burn shock is imminent.

Fluid Resuscitation Initial 24 hours:
Lactated ringer's 2-4 ml/kg/%burn/24 hours - given in the first 8 hours post-injury. Additional fluid required for inhalation injury. Maintain urine output of 30 ml/hr. 5% albumin – keep albumin >2.5 gm/dl Fluid Resuscitation The most crucial aspect of early care of the burn patient is prompt initiation of volume replacement of large quantities of salt-containing fluids sufficient to maintain adequate perfusion of vital organs. Many formulas for burn resuscitation have proven clinically efficacious, and each differs in volume, sodium, and colloid content. Currently, the most widely used Adult formulas are the Parkland (Baxter) formula and the modified Brooke formula, which deliver Ringer's lactate solution (LR) at 4 ml/kg/%burn and 2 ml/kg/%burn respectively, during the first 24 hours post-burn. In each case, half of this volume is administered in the first eight hours post-burn. The rate is adjusted hourly to assure a urinary output of 30 ml/hr in adults and 1 ml/kg/hr in children. Serum albumin is replaced to keep levels >2.5 gm/dl. NOTE: A 60 kilogram adult with a 40% body surface area burn will receive ml of Lactated Ringer’s in the first 24 hours post-burn; ml of this will be given in the first 8 hours post-burn. That means the patient will receive ml/hr for the first 8 hours. This is calculated from the time of the burn, not from the time of admission.

Monitoring Fluid shift lasts 24 to 72 hours.
Hematocrit, electrolytes, osmolality, calcium, glucose, albumin Urine output >30 ml/hr Myoglobinuria and hemoglobinuria Pulse rate and pulse pressure Normal sensorium and adequate peripheral capillary refill Monitoring The acute resuscitation period following burn injury generally lasts 24 to 72 hours. Fluid shifts are rapid. Serial determinations of hematocrit, serum electrolytes, osmolality, calcium, glucose and albumin can help direct appropriate fluid replacement. Persistent metabolic acidosis on arterial blood gases may be indicative of ongoing hypoperfusion from hypovolemia. The single best monitor of fluid replacement is urine output. Acceptable hydration is indicated by a urine output of more than 30 ml/hr is an adult (0.5 ml/kg/hr) and at least 1 ml/kg/hr in a child. Diuretics are generally not indicated during the acute resuscitation period. Patients with high voltage electrical burns and crush injuries have an increased risk of renal tubule obstruction from myoglobinuria and hemoglobinuria. Urine output should be maintained at 1-2 ml/kg/hr, if pigment can be seen in the urine and the urine alkalinized with IV sodium bicarbonate or acetazolamide with IV mannitol to aid in diuresis and to act as a free radical scavenger. Pulse rate and pulse pressure are more sensitive indicators of hemodynamic status than blood pressure. Hypotension is a late finding in burn shock. Normal sensorium and adequate peripheral capillary refill are additional clinical indicators of adequate organ perfusion. Invasive hemodynamic monitoring with central venous catheters, arterial lines, and Swan Ganz catheters is usually not needed in the absence of a severe inhalation injury, and discretion is advised. Pulmonary artery lines especially carry an inordinate risk of sepsis, thrombophlebitis and endocarditis in thermal injury patients. (Shriner’s Hospital burn care orientation:

Type Cause Priority Thermal Flame, steam, liquids Smother flames; Remove smoldering clothing & metal objects Chemical Acids, strong alkalis, organic compounds Brush off dry chemicals Remove clothing; ascertain type of chemical Electrical Direct or alternating current Lightning Separate patient from electrical current Smother any flames Start CPR; Obtain EKG Radiation Solar, X-rays Radioactive agents Remove from radiation source Remove clothing if contaminated using tongs or lead gloves Send to radiation decontamination center

Skin Care Hydrotherapy daily to debride eschar and cleanse wounds
Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidly Silver coated anti-microbial dressing (Acticoat) Skin care: The goal in treating burns is to prevent/control infection, prevent wound progression, cover the wound as soon as possible, and promote function of the healing skin. Several different approaches may used including: Hydrotherapy daily to debride eschar and cleanse wounds Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidly Silver coated anti-microbial dressing (Acticoat)

Allograft (skin from a cadaver) Synthetic such as Biobrane
Grafting: Allograft (skin from a cadaver) Synthetic such as Biobrane Bioengineered skin substitute (Transcyte) If skin grafting is necessary one or more of these may be used as a temporary protection: Allograft (skin from a cadaver) Synthetic such as Biobrane Bioengineered skin substitute (Transcyte):

Prevention of Pressure Ulcers
Patients at risk Inspect skin frequently Move at least every 2 hours Use life sheet or slide board Pad bony prominences Remove excess moisture Adequate nutrution Use protective barriers Identify patients at risk for skin breakdown using an assessment such as the Braden scale. Inspect the patient’s skin frequently for signs of increased pressure. Positioning: move patient at least every 2 hours to decrease pressure on skin. Use a lift sheet or slide board to move patient. Pad bony prominences: sacrum, elbows, heels, back of head. Remove excess moisture from skin: urine, feces, sweat. Nutrition: maintain adequate hydration, protein and calorie intake. Use protective barriers such as a hydrocolloid dressing (Duoderm) in high risk areas:

Braden Scale 1 2 3 4 Sensory Completely limited Very limited
Slightly limited No impairment Moisture Constantly moist Very moist Occasionally moist Rarely moist Activity Bedfast Chairfast Walks occasionally Walks frequently Mobility Completely immobile No limitations Nutrition Very poor Probably inadequate Adequate Excellent Friction/ Shear Problem Potential problem No apparent problem The lower the score, the higher the risk for skin breakdown. Identify patients at risk for skin breakdown using an assessment such as the Braden scale. Areas assessed are: Sensory perception: Ability to respond meaningfully to pressure-related discomfort Moisture: degree to which skin is exposed to moisture Activity: degree of physical activity Mobility: ability to change or control body position Nutrition: usual food intake pattern Friction and shear

Pressure Ulcers Stage I: Redness only
Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

Stage 2 Pressure Ulcer Loss of epidermis and partial loss of dermis not extending into subcutaneous tissue Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

Stage 3 Pressure Ulcer Full thickness wound
Stage 3 Pressure Ulcer Full thickness wound. Includes loss of epidermis and dermis. Extends into subcutaneous tissue. Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

Stage 4 Pressure Ulcer Deep penetrating wound
Stage 4 Pressure Ulcer Deep penetrating wound. Includes loss of epidermis, dermis and subcutaneous tissue. Extends into muscle and/or bone. Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures

Basal Cell Carcinoma Malignancy of the basal cell layer of the epidermis. Genetic predisposition, chronic irritation, and ultra-violet exposure are risk factors. Photo Source: Wikimedia Commons

Squamous Cell Carcinoma
Cancers of the epidermis Chronic irritation, skin damage risk factors Photo Source: Wikimedia Commons

Malignant Melanoma Pigmented cancers in the melanin-producing epidermal cells. Risk factors: predisposition, excess ultra-violet exposure. Photo Source: Wikimedia Commons

Preventing Skin Cancer
Avoid sun between 11:00 am and 3:00 pm Use sunscreen Wear a hat, opaque clothing, sunglasses in the sun Examine body monthly for lesions Prevention

Seek Medical Attention
Changes color, especially darkening or spreading Changes in size Change in shape – sharp border becomes irregular or flat becomes raised Surrounding redness or edema Change in sensation, especially itching or tenderness Change in character: oozing, crusting, bleeding, scaling

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.

Med/Surg I, Module 4 Part 1 of 4

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Med/Surg I, Module 4 Part 1 of 4

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