Presentation on theme: "Med/Surg I, Module 4 Part 1 of 4"— Presentation transcript:
1 Med/Surg I, Module 4 Part 1 of 4 Orthopedic SystemAlteration in MobilityIntegumentary System
2 Chronic Musculoskeletal Conditions Curvature of the SpineOsteoporosisOsteomyelitisOsteoarthritis
3 Curvature of the Spine Kyphosis (left) and Lordosis (right) Kyphosis ManifestationsLoss of bone mass related to agingLoss of height with progressive spine curvature, low back painKyphosis (“dowager’s hump”) and cervical lordosisIncreased bone fragilityIncreased risk of fractures of forearm, spine, hipKyphosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.LordosisSource: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center.
4 Source: Wikimedia Commons, Public Domain ScoliosisSource: Wikimedia Commons, Public Domain
5 Osteoporosis Increased Risk Family history Female Menopause-related low estrogen females, low testosterone malesMedicationsLifestyleFamily history, especially small frame Asians & white femalesFemaleMenopause-related low estrogen females, low testosterone malesUse of anticonvulsants, corticosteroids, heparin, tetracycline, thyroid supplementsLifestyle: inactive, cigarette &/or alcohol use, low lifetime calcium intake
6 Osteoporosis Prevention Diet Calcium supplements Stop smoking Alcohol and caffeine intakeweight-bearing exerciseSunlightIncrease dietary calcium & vitamin D: milk & milk products best sources; sardines, clams, oysters, salmon, dark green leafy vegetablesTeach calcium in diet: Calcium supplements post menopauseStop smokingDecrease alcohol and caffeine intakeIncrease weight-bearing exercise: at least 30 minutes 3 times per weekIncreased exposure to sunlight: vitamin D increases calcium absorption in intestine
7 Osteoporosis Diagnosis Dual-energy x-ray absorptiometry (DEXA) scan Qualitative ultrasound (QUS) of heel or calcaneusDiagnosisDual-energy x-ray absorptiometry (DEXA) scan measures bone mineral density in hip, wrist or vertebrae: best toolQualitative ultrasound (QUS) of heel or calcaneus: low cost screening tool
8 Osteoporosis Collaborative Management Replace estrogen or testosterone Raloxifene (Evista)Biphosphonates: Alendronate (Fosamax) and risedronate (Actonel)Teriparatide (Forteo)Ibandronate sodium (Boniva)Calcitonin (Miacalcin)Sodium fluorideCollaborative Management: retard bone resorption:Replace estrogen after menopause orRaloxifene (Evista): mimicks estrogen effect on bones without risks of estrogenBiphosphonates: Alendronate (Fosamax) and risedronate (Actonel) inhibit bone resorptionTeriparatide (Forteo): synthetic parathyroid increases new bone formationIbandronate sodium (Boniva): both prevents bone loss & increases bone densityCalcitonin (Miacalcin): increases bone formation, decreases resorptionSodium fluoride stimulates bone formation
9 Osteoporosis Nursing Care Prevent falls Treat pain Orthotic devices Refer to physical therapyRange of motion exercisesNursing CarePrevent falls: use assistive devices prnTreat pain: nonsteroidal anti-inflammatory drugs (NSAIDS)Orthotic devices to support spineRefer to physical therapy to strengthen abdominal and back musclesRange of motion exercises to maintain joint mobility
10 Osteomyelitis Local swelling Redness Tenderness Pain Fever Bone pain Clinical ManifestationsLocal swelling, redness, tenderness, painFeverBone pain: constant, localized, pulsating; intensifies with movementSource: UCSD Catalog of Clinical Images, Photographs by Charlie Goldberg, M.D.,UCSD School of Medicine and VA Medical Center, San Diego, California,
12 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 WBCMost cases caused by Staphylococcus aureus:Parenteral antibiotics based on wound, blood cultures for 4-6 weeks orOral twice-daily ciprofloxacin if chronicHyperbaric oxygen therapy to promote healingCollaborative CareSurgical debridement is the primary treatmentPostoperative care: wound irrigation with strict sterile technique; monitor site for signs of infection, monitor temperature and WBCMost cases caused by Staphylococcus aureus:Parenteral antibiotics based on wound, blood cultures for 4-6 weeks orOral twice-daily ciprofloxacin if chronicHyperbaric oxygen therapy to promote healing
13 OsteoarthritisOsteoarthritis, 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 CenterReprinted with permission: DePuy Orthopaedics, Inc.
14 Clinical Manifestations CrepitusJoint stiffnessPain with movementHeberden’s nodes (distal joints) and Bouchard’s nodes (proximal joints)Knees: Joint effusionsMuscle atrophySpine: radiating pain, stiffness, muscle spasms in extremitiesHips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotationClinical ManifestationsCrepitus: grating sensation as joint movesJoint stiffness following inactivity that decreases with a few minutes of movementPain with movement, relieved by resting the jointHands: 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 disuseSpine: radiating pain, stiffness, muscle spasms in extremitiesHips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotation
15 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 spasmRest: splint or brace - balance rest and activity to maintain mobility; adequate sleep at night + napPositioning: place joints in functional position, small neck pillow but avoid other pillows to prevent flexion contractures; use proper postureHeat: 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 degenerationTranscutaneous electrical nerve stimulation (TENS): Transmission of low-voltage electrical impulses from a handheld battery-powered generator to the skin via surface electrodes.
16 Total Joint Arthroplasty Source: Hughston FoundationSource: Hughston Foundation
17 Postoperative Care Abduction pillow, neutral position Prevent embolus Prevent infectionAssess for bleedingNeurovascular compromiseManage painPromote activityPostoperative care:Prevent joint dislocation (subluxation)Abduction pillow, leg in neutral rotationWatch for dislocation (pain, shortening, leg rotation)Prevent thromboembolismCompression stockings, pumpsAnticoagulantsLeg exercisesPrevent infectionMonitor incision, check drainageCheck temperature, WBCsAssess for bleedingBlood salvage, reinfusion up to 4 hoursMonitor dressing, drainsEpoetin alfa (Epogen)Assess for neurovascular compromiseColor, sensation, movement (CSM), compare with opposite legLocal temperature, distal pulses, capillary refillManage painPatient-controlled analgesia (PCA)Bupivacaine (Marcaine) pump directly into surgical sitePromote activityAmbulate day after surgeryRaised toilet seat (no flexion beyond 90 degrees)Straight-back chair, walker, physical therapyPartial weight bearing if prosthesis uncemented
18 Total Knee Arthroplasty Continuous passive motion (CPM) deviceIce or hot/ice machineKeep knee in neutral, no rotation inward or outwardMonitor: thromboembolism, infection, bleeding, CSMTeach: no hyperflexion or kneeling for 6 weeksTotal Knee ArthroplastyContinuous passive motion (CPM) device: keeps knee in motion, prevents scar tissueSet for degrees of range and number of cycles/minuteIntermittent for several hoursCheck padding, postioning in machineIce or hot/ice machineKeep knee in neutral, no rotation inward or outwardMonitor: thromboembolism, infection, bleeding, CSMTeach: no hyperflexion or kneeling for 6 weeks
20 Open or Closed? Closed – No break in the skin Open (also called “Compound”)Complete - Entire width of bone broken, divided into 2 sectionsIncomplete - Break is through only part of the bone; also called “Greenstick”Comminuted – Several bone fragmentsPhoto source: American Academy of Orthopaedic Surgeons,
21 Compound Fractures Grade I Grade II Grade III Small wound ~1 cm to 10 cmskin & muscle contusionsGrade IIILargeDamaged skin, muscle, nerves, vesselsGrade I: Clean wound, less than 1 cm longGrade II: Larger wound, skin and muscle contusions, no extensive soft tissuedamageGrade III: Wound larger than 1 cm, highly contaminated, damage to skin, muscle,nerve tissue and blood vessels extensive soft tissue damage
22 Assessment Can he move it? Does it hurt? Is it deformed? Deformity Local edema, ecchymosisPain/tendernessCrepitusEcchymosisEmergency CareImmobilize: splint joint above through joint below fractureTissue perfusion: Apply direct pressure to control bleeding, assess distal pulsesPrevent infection: Cover open wounds with sterile dressing
23 Key Treatments Closed reduction Immobilization Open reduction Splint CastOpen reductionClosed 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 FixationNational Institutes of Health Osteoporosisand Related Bone Diseases National ResourceCenter
24 Cast Care Prevent indentations when wet Elevate uniformly Air dry CSM – What am I looking for?No scratching implements!Cast CarePrevent 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 dryColor, Sensation, Movement (CSM): Assess q 15 minutes x 4 hours, then q 1 hour until 24 hours post castingTeach: No scratching implements
25 Skin Traction To decrease muscle spasm Weight 5-7 pounds attached w/ adhesive tapeUsed before surgical repairCheck sling, tape for placementKeep pulley, weights in placeSkin TractionTo decrease muscle spasmFive-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 tapeWeights 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 repairMake 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 placementKeep pulley, weights in placePhoto Source: Royal College of Surgeons of Ireland (RCSI), Creative Commons
26 Buck’s Traction Hip fracture assessment What to do immediately? Buck’s traction assessmentsWhat should be done later?What teaching is needed?Buck’s: NURSING, Nov 2003 by Sprauve, DoyleanAGNES 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 TractionSource: DeRoyal Patient Care
27 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.
28 Skeletal Traction Weight 25-40 pounds Are the ropes on the pulleys? Are the weights hanging free?Where are the knots?Monitor CSMPin care?Skin careSkeletal TractionSkeletal 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 dislocationsmaintain body or limb alignmentdecrease muscle spasms and relieve paincorrect, lessen or prevent musculoskeletal deformitypromote rest of an injured or diseased partpromote exerciseNursing ManagementWeight poundsAre the ropes on the pulleys?Are the weights hanging free?Where are the knots? (should not be on pulleys)Monitor CSMPin careSkin care
29 Balanced Suspension Counter-traction by weights Check ropes, knots, weightsAre 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 bodyprovides 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 fastenedAssess for correct positioning of traction and alignment of affected extremityand 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• drainageREPORTABLE 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 extremityAttach 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.
30 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.
32 Compartment Syndrome Prevention Emergency care Check CSM Ice, elevate Loosen dressing, open castEmergency careFasciotomy:Compartment Syndrome: patient complains of pain, tingling, tightness, fullness in muscle, then numbness, cell deathPreventionCheck CSMIce, elevateLoosen dressing, open castEmergency careFasciotomy
33 Fat Embolism Long bones, multiple fractures Elderly: hip fractures Altered mental statusRespiratory distressPetechiae on trunkPrevention: early immobilization of fractureFat EmbolismHighest risk: Long bones, multiple fracturesElderly: hip fracturesSigns and Symptoms:Altered mental statusRespiratory distressPetechiae on trunkPrevention: early immobilization of fracture
34 Deep Venous Thrombosis Most common complicationPredisposing factorsCommon sites: leg, pelvic fxPulmonary embolus preventionDeep Venous ThrombosisMost common complicationPredisposing factors: Predisposing factors complicate the risk: obesity, smoker, heart disease, taking oral contraceptives or hormones, history of thromboembolic conditionsCommon sites: leg, pelvic fracturesPrevention: Preventing a pulmonary embolus: mobilize unaffected extremities, assess legs for size variations, pain unrelieved by usual medication dosages.Deep Vein ThrombosisSource: National Heart & Blood Institute
35 Osteomyelitis Sources: open wounds, implanted hardware Staphylococcus aureus usuallyRx: IV antibioticsOsteomyelitisSources: open wounds, implanted hardwareStaphylococcus aureus usuallyTreatment: IV antibioticsOsteomyelitis 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 diabetesPatients receiving hemodialysisPeople with weakened immune systemsPeople with sickle cell diseaseIntravenous drug abusersThe elderlySymptoms of osteomyelitis The symptoms of osteomyelitis can include:Pain and/or tenderness in the infected areaSwelling and warmth in the infected areaFeverNausea, secondarily from being ill with infectionGeneral discomfort, uneasiness, or ill feelingDrainage of pus through the skinAdditional symptoms that may be associated with this disease include:Excessive sweatingChillsLower back painSwelling of the ankles, feet, and legs
36 Aseptic Necrosis Death of bone tissue Hip fractures or bone displacementHardware interferes with circulationAseptic NecrosisDeath of bone tissueSeen in: Hip fractures or bone displacementHardware interferes with circulation
37 Amputation Diabetic, smoker, infected foot ulcer Trauma Grieving loss Altered self conceptCopingFamily responseLargest 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 chemicalsAmputationLargest population: diabetic, smoker, infected foot ulcersManage:Tissue perfusion: monitor skin flap CSM, Doppler pulsePain: stump pain versus phantom limbPrevent infection: keep dressing intact, reinforce prnPromote ambulation: Trapeze, range of motionFlexion contractions (leg amputation): prone position q 3-4 hours, avoid pillows that flex hip or kneeProstheses: prosthetist-orthotist referralWrap stump firmly with elastic bandages, figure-eight, reapply q 4-6 hours to reduce edema
38 Surgical Wounds Web Resource Click tab titled, “Med-Surg 1”Drop down menu choose “Wound Care”Risk Assessmentmental statusmobilityactivitynutrition/hydrationcirculationmoisture exposureAssess patient's general statuswound disrupts patient's entire lifepatient disease state that affects wound statuswound etiology and type (acute vs. chronic)
39 Wound Assessment Measure the wound in centimeters Assess phase of wound healingReactionRegenerationRemodelingWound location, color of wound bed, condition of wound margins, integrity of surrounding skinSigns and symptoms of infectionDrainage: amount, color, consistency, odorWound AssessmentMeasure the wound in centimeters · Length (head to toe) X width (side to side) X depthIndicate deepest point using clock method (e.g. 6:00 5 cm)Depth cannot be accurately measured in the presence of necrotic tissueMeasure depth and tunneling with a cotton swabSketch wound in notes and place digital picture with date and time in chartAssess phase of wound healingReactionRegenerationRemodelingWound location, color of wound bed, condition of wound margins, integrity of surrounding skinSigns and symptoms of infectionDrainage: amount, color, consistency, odor
40 Wound Care Dressing The ideal dressing Keeps wound moist Prevents macerationProtects from contaminationContains wound fluidProtects granulation tissueWound Care DressingsCharacteristics of an ideal dressingkeep wound moistprevent macerationprotect from contaminationcontain wound fluidprotect granulation tissue
41 Traditional dry dressings Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist woundsEpithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing timeNonocclusive: increased risk of contamination and infectionTraditional dry dressingsWounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds during the inflammatory stage of healingdecreased collagen productiondermis is more fibroplastic, fibrotic and scarredEpithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing timegreater paingreater costincreased frequency of dressing changes (bid, tid, qid)Nonocclusive: increased risk of contamination and infection
42 Moist Wound Healing No eschar develops (crust, scab) Enhances autolytic debridement: promotes role of macrophages and leukocytesBacterial barriers: prevent wound contaminationWound fluids kept at site: contain growth factors and enzymes that promote autolysis and healingMoist wound healingWound kept moist and protected from external environmentno eschar develops (crust, scab)enhances autolytic debridement: promotes role of macrophages and leukocytesbacterial barriers: prevent wound contaminationwound fluids kept at site: contain growth factors and enzymes that promote autolysis and healingPotential for infectionPotential for increasing pathogen growthuse carefully with immunocompromised patientsoccluded wounds show a shift from gram-positive to gram-negative organismsSigns of infectionI-indurationF-feverE-erythemaE-edemaWound cultures need to be quantitative. Wound infection: > 105 colony forming units (CFU) of a specific pathogen per gram of tissueAccumulation of drainageExudate: 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 epithelializationGeneral PrinciplesWounds generally get worse before they get better as ischemic tissue sloughsOdor often worsensSeveral 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 mechanismWounds can generally be treated based on appearance and drainage (scab) healing is slower
43 Potential for Infection Signs of infectionI-indurationF-feverE-erythemaE-edemaPotential for infectionPotential for increasing pathogen growthuse carefully with immunocompromised patientsoccluded wounds show a shift from gram-positive to gram-negative organismsSigns of infectionI-indurationF-feverE-erythemaE-edemaWound cultures need to be quantitative. Wound infection: > 105 colony forming units (CFU) of a specific pathogen per gram of tissueAccumulation of drainageExudate: 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 epithelializationGeneral PrinciplesWounds generally get worse before they get better as ischemic tissue sloughsOdor often worsensSeveral 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 mechanismWounds can generally be treated based on appearance and drainage (scab) healing is slower
44 Absorptive powders and pastes Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levelsMay require wrapping in gauze before inserting into wound bed Pastes easier to remove from woundAbsorptive powders and pastesUsually 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 levelsMay require wrapping in gauze before inserting into wound bedPastes easier to remove from wound
45 Wound Healing Normal healing (3R's) Reaction: inflammatory process (72 hours)Regeneration: proliferation (up to three weeks)Remodeling: (three weeks to two years)Wound HealingNormal healing (3R's)Reaction: inflammatory process (72 hours)Regeneration: proliferation (up to three weeks)Remodeling: (three weeks to two years)
46 Black Wound = EscharCellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissueIf eschar becomes contaminated:becomes excellent medium for infectionwound remains in reaction or inflammatory stagesystemic signs of infectionEschar delays regeneration phase by interfering with cell migration and wound closureRisk of wound infection increases as the amount of necrotic tissue increasesNeeds debridementBlack wound: most often in late reaction or early regeneration phaseMacrophages are migrating to injury to clean up bacteria and debrisGrowth factors stimulating new vascular growth at wound base (angiogenesis), fibroblast migration and fibroblast proliferationCollagen being deposited, filling wound with scar tissueIf eschar left intact and kept dry:cellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissueusually only inflamed around edgesIf eschar becomes contaminated:becomes excellent medium for infectionwound remains in reaction or inflammatory stagesystemic signs of infectionEschar delays regeneration phase by interfering with cell migration and wound closureRisk of wound infection increases as the amount of necrotic tissue increasesNeeds debridement
47 Yellow WoundTissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudateHigh risk of infection due to excellent medium for bacterial growthNeeds continuing debridementYellow wound (yellow necrosis or slough): tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudateUsually in late reaction or early regenerationHigh risk of infection due to excellent medium for bacterial growthRegeneration phase continuing with earlier wound contraction than with the thick escharNeeds continuing debridementPhoto courtesy of Saddleback College, California,
48 Red Wound Red indicates presence of granulation tissue. Color of granulation tissue affected by nutritional status and blood supplyfull thickness ulcer: crater with pale pink to beefy red granulation tissuecrater slowly fills with granulation tissue from bottom upwardWound 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 supplyfull thickness ulcer: crater with pale pink to beefy red granulation tissuecrater slowly fills with granulation tissue from bottom upwardWound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.
49 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 devicesWound Drainage DevicesThese 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
50 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/EviscerationWound 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.
51 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 contaminationCommon Skin InfectionsBacterial 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
52 Herpes Simplex VirusType 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 infectionHerpes 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
53 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.
58 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,
59 Emergency ManagementExcessive 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 ManagementIn 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.
60 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/dlFluid 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.
61 Monitoring Fluid shift lasts 24 to 72 hours. Hematocrit, electrolytes, osmolality, calcium, glucose, albumin Urine output >30 ml/hrMyoglobinuria and hemoglobinuriaPulse rate and pulse pressureNormal sensorium and adequate peripheral capillary refillMonitoringThe 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:
62 TypeCausePriorityThermalFlame, steam, liquidsSmother flames; Remove smoldering clothing & metal objectsChemicalAcids, strong alkalis, organic compoundsBrush off dry chemicals Remove clothing;ascertain type of chemicalElectricalDirect or alternating currentLightningSeparate patient from electrical currentSmother any flamesStart CPR; Obtain EKGRadiationSolar, X-raysRadioactive agentsRemove from radiation sourceRemove clothing if contaminated using tongs or lead glovesSend to radiation decontamination center
63 Skin Care Hydrotherapy daily to debride eschar and cleanse wounds Topical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidlySilver 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 woundsTopical enzyme such as collagenase (Santyl) or Accuzyme will debride more rapidlySilver coated anti-microbial dressing (Acticoat)
64 Allograft (skin from a cadaver) Synthetic such as Biobrane Grafting:Allograft (skin from a cadaver)Synthetic such as BiobraneBioengineered 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 BiobraneBioengineered skin substitute (Transcyte):
65 Prevention of Pressure Ulcers Patients at riskInspect skin frequentlyMove at least every 2 hoursUse life sheet or slide boardPad bony prominencesRemove excess moistureAdequate nutrutionUse protective barriersIdentify 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:
66 Braden Scale 1 2 3 4 Sensory Completely limited Very limited Slightly limitedNo impairmentMoistureConstantly moistVery moistOccasionally moistRarely moistActivityBedfastChairfastWalks occasionallyWalks frequentlyMobilityCompletely immobileNo limitationsNutritionVery poorProbably inadequateAdequateExcellentFriction/ShearProblemPotential problemNo apparent problemThe 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 discomfortMoisture: degree to which skin is exposed to moistureActivity: degree of physical activityMobility: ability to change or control body positionNutrition: usual food intake patternFriction and shear
67 Pressure Ulcers Stage I: Redness only Photo courtesy of Saddleback College: Assisted Learning for All nursing procedures
68 Stage 2 Pressure Ulcer Loss of epidermis and partial loss of dermis not extending into subcutaneous tissuePhoto courtesy of Saddleback College: Assisted Learning for All nursing procedures
69 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
70 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
71 Basal Cell CarcinomaMalignancy of the basal cell layer of the epidermis.Genetic predisposition, chronic irritation, and ultra-violet exposure are risk factors.Photo Source: Wikimedia Commons
72 Squamous Cell Carcinoma Cancers of the epidermisChronic irritation, skin damage risk factorsPhoto Source: Wikimedia Commons
73 Malignant MelanomaPigmented cancers in the melanin-producing epidermal cells.Risk factors: predisposition, excess ultra-violet exposure.Photo Source: Wikimedia Commons
74 Preventing Skin Cancer Avoid sun between 11:00 am and 3:00 pmUse sunscreenWear a hat, opaque clothing, sunglasses in the sunExamine body monthly for lesionsPrevention
75 Seek Medical Attention Changes color, especially darkening or spreadingChanges in sizeChange in shape – sharp border becomes irregular or flat becomes raisedSurrounding redness or edemaChange in sensation, especially itching or tendernessChange in character: oozing, crusting, bleeding, scaling
76 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.
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