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Traumatic Emergencies: Laceration Introduction The organized systematic care process outlined in this section optimally manages the patient with a laceration. The steps include assessment, problem identification, planning, interventions, ongoing evaluations, and disposition. Detailed information is included for the common medications used for patients with a laceration. The related information section at the end of the chapter provides an overview of terms, concepts, and pathophysiology related to lacerations. Topics reviewed include: AnesthesiaFacial lacerations Hemophilia Management of lacerations Points to control arterial hemorrhage Suture removal times Review of wound closures Rapid ABC Assessment Is the patient’s airway patent?The airway is patent when speech is clear and no noise is associated with breathing. If the airway is not patent, consider clearing the mouth and placing an adjunctive airway. Is the patient’s breathing effective? Breathing is effective when the skin color is within normal limits and the capillary refill is < 2 seconds. If breathing is not effective, consider administering oxygen and placing an assistive device. Is the patient having any pain or tenderness of the spine? Immobilize the C-spine for neck pain or tenderness if the injury is less than 48 hours old. Place a hard C-collar on the neck and immobilize the back by laying the patient on a stretcher. Is the patient’s circulation effective? Circulation is effective when the radial pulse is present and the skin is warm and dry. If circulation is not effective, consider placing the patient in the recumbent position, establishing intravenous access, and giving a 200 ml fluid bolus. Use the Glasgow Coma Scale to evaluate the disability of the trauma patient? Add the scores of eye opening, best verbal, and best motor.If the score is less than 8, consider endotracheal intubation and mechanical ventilation to reduce the risk of hypoventilation and aspiration. NOTE: Control a hemorrhage of the extremities by elevating the extremity above the level of the heart and compress the area. With the elevation of the extremity maintained, a compression bandage will control the bleeding.
Patient Identification The patient’s identity, chief complaint, and history of present illness are developed by interview. The standard questions are who, what, when, where, why, how, and how much. Who identifies the patient by demographics, age, sex, and lifestyle. What develops the chief complaint that prompted the patient to seek medical advice. When determines the onset of the symptom. Where identifies the body system or part that is involved and any associated symptoms. Why identifies precipitating factors or events. How describes how the symptom affects normal function. How much describes the severity of the affect Who is the patient? What is the patient’s name? What is the patient’s age and sex? What is the name of the patient’s current physician? Does the patient live alone or with others? Chief Complaint The chief complaint is a direct quote stating the main symptom that prompted the patient to seek medical attention. A symptom is a change from normal body function, sensation, or appearance. A chief complaint is usually three words or less and not necessarily the first words of the patient. Some investigation may be needed to determine the symptom that prompted the patient to come to the ER. When the patient, or other, gives a lengthy monologue, a part of the whole is quoted. In one to three words, what is the main symptom that prompted the patient to seek medical attention? Use direct quotes to document the chief complaint.Acknowledge the source of the quote, e.g., the patient states; John Grimes, the paramedic states; Mary, the granddaughter, states. History of Present Illness When did the patient sustain the laceration?Where is the laceration and are any associated symptoms present? What caused the laceration, e.g., slip and fall, syncope? How does the laceration affect the patient’s normal function? What is the initial impression of the severity of the laceration, e.g., laceration of skin and subcutaneous tissue, laceration of muscle, tendons? Is any bleeding present? Does the patient have normal neurovascular function distal to the laceration? Does the patient have normal use of the injured area? Has any treatment been initiated and has it helped? Has the patient had serious injury to the same area in the past? When was the injury? What was the diagnosis and treatment? Is unlawful activity suspected? Was law enforcement at the scene? What agency? Medical personnel are obligated to notify law enforcement if unlawful activity is suspected. Does the patient have any pertinent past history? Does the patient take any routine medications? What is the name, dosage, route, and frequency of the medication? When was the last dose? Does the patient have allergies to drugs or foods? What is the name of the allergen? What was the reaction? When was the patient’s last tetanus immunization? If the patient is female and between the ages of 12 to 50 years, when was the first day of her last menstrual period? Nursing Diagnoses Knowledge deficit Pain AnxietyAnticipated Medical Care
Initial Assessments and Interventions Ask the patient to remove clothes and jewelry near the laceration.Get vital signs. Position the patient in a relaxed anatomically correct position that allows easy access to the lacerated area for irrigation and repair. Perform a focused examination of the laceration. Assess the laceration size and depth.Evaluate neurovascular function distal to the laceration. Evaluate motor function distal to the laceration. Clean, irrigate, and cover the laceration with sterile saline moistened gauze. Give tetanus toxoid if indicated. Set up suture equipment on a stand within easy access of the laceration. Suture tray with washing solutionsSterile gloves in the proper size for the person doing the suturing. Local anesthesia in a syringe placed within easy reach. Kick bucket for waste placed within easy reach. A spotlight placed behind the shoulder of the person suturing and directed down towards the laceration. Suture material if known. The usual practice is to have the person doing the suturing select the suture material and the needle size and shape. Instruct the patient not to eat or drink and teach the rationale for the NPO status. Elevate the siderails and place the stretcher in the lowest position. Inform the patient, family, and caregivers of the usual plan of care and the expected overall time in the ER. Provide the patient with a device to reach someone for assistance and explain how to use it. Ask the patient to call for help before getting off the stretcher. Ongoing Evaluations and Interventions Inform the physician of adverse changes noted during ongoing evaluation. Document that the physician was notified of the adverse change and what orders, if any, were received. Monitor vital signs. Monitor therapy closely for the patient’s therapeutic response. The usual time for a medication effectiveness check is 20 to 30 minutes after giving the drug. If therapy is not effective, ask the physician for a repeat dose or an alternative. Monitor closely for the development of adverse reactions to therapy. Perform interventions to relieve the adverse reaction. Ask the physician for a remedy. If not NPO, provide the patient with food at mealtimes and fluids during the stay. Keep the patient, family, and caregivers well informed of the plan of care and the remaining time anticipated before disposition. Monitor the patient’s laboratory and x-ray results and notify the physician of critical abnormalities. Remedy abnormalities as ordered. Notify the physician when all diagnostic results are available for review. Ask for establishment of a medical diagnosis and disposition. Discharge Instructions Provide the patient with the name of the nurse and doctor in the emergency room. Inform the patient of their diagnosis or why a definitive diagnosis couldn’t be made. Explain what caused the problem if known. Teach the patient how to take the medication as prescribed and how to manage the common side effects. Instruct the patient not to drive or perform any dangerous tasks while taking narcotic pain medications. Instruct the patient that: After a laceration is sutured, keep it clean and dry. After one or two days, the dressing applied in the ER may be removed and the wound left open to the air. Some lacerations of the face and scalp are not covered with a dressing in the ER. The wound may be covered with a dry sterile dressing if needed to protect the area. Elevation of the area when possible will reduce the risk of swelling. After the dressing is removed, the laceration should be kept clean with mild soap and water and an antibiotic over-the-counter ointment be applied two times a day for the first three days. Follow-up is recommended for suture removal. Some lacerations contaminated with dirt or bacteria are not sutured. These are considered dirty wounds and further care is necessary at home. The area should be soaked in warm water and diluted Betadine (one part Betadine and twenty parts of water) for twenty minutes three times a day for the first three days. The wound should be covered with a dry sterile dressing between soaks. If the wound is dry and clean after three days of soaks, stop the soaking, and keep it clean, dry, and covered. Not all dirty wounds need antibiotics. If antibiotics are prescribed, take them until the pills are gone. Do not stop when the wound looks better. Redness, swelling, red streaks, and pus are signs of infection. Notify the follow-up physician if any of these symptoms develop. For the patient with soft tissue injury teach the mnemonic PRICE. When the injured area is not managed properly, the patient pays the PRICE of increased pain and disability. Protect the injured area and keep out of harms way. Cover skin that is not intact with a sterile dressing when in a dirty environment. Rest the area. Do not use or walk on an injured extremity. Ice the area. Compress the area with light pressure from a compression bandage or ice pack to reduce the risk of swelling. Elevate the injured area above the level of the heart. Recommend a physician for follow-up care. Provide the name, address, and phone number with a recommendation of when to schedule the care. Instruct the patient to call the follow-up physician immediately or return to the emergency room if the pain or problem worsens in anyway or any unusual symptoms develop. Encourage the patient NOT to IGNORE WORSENING OR PERSISTENT SYMPTOMS. Ask for verbal confirmation or demonstration of understanding and reinforce teaching as needed. Commonly Used Medications
Related Information Anesthesia Anesthesia is usually done by local infiltration or regional block. Sedation or conscious-sedation can be used. Avulsion An avulsion is a full-thickness skin loss and approximation of the skin edges is impossible. Control of External Hemorrhage For hemorrhage of the extremities, elevate the extremity as high as possible above the heart level and compress the area. With the elevation of the extremity maintained, a compression bandage will control the bleeding. Contusion A contusion is an altered area of skin integrity caused by blunt trauma.
Facial Lacerations Keep the tissue moist with saline gauze before cleaning, after cleaning, and before suturing to minimize devitalization of the tissue. Keeping the tissue vital is beneficial for skin layer matching and to minimizing scarring. Betadine and peroxide can be caustic to tissue. Facial sutures should be removed in 3-5 days to further minimize scarring. Hemophilia Even minor trauma can cause major bleeding in the patient with hemophilia. Hemorrhage can occur anywhere in the body. Bleeding into a joint is extremely painful and leads to severe disability. Patients usually have severe pain associated with a joint bleed. The patients and family are knowledgeable about the disease. Therapy is FFP for hemophilia A and von Willebrand’s disease and factor VII for hemophilia B. Patients often have factor VII at home, but are unable to give it because of difficult intravenous access from repeated transfusions. Cryoprecipitate contains factor VIII. Most hemophiliac patients require large doses of narcotic analgesia because frequent use is necessary and a tolerance is built. Most patients know the amount of medication necessary to relieve their pain. Patients are often under treated by physicians for fear of contributing to an addiction. Laceration Lacerations are open cuts. Superficial lacerations are through the epidermis and dermis. Deep lacerations involve the deep muscle layers.
Suture Removal
Tetanus Prone Wounds Wounds greater than six hours old, avulsed, crushed with devitalized tissue, or contaminated with dirt, feces, or salvia are considered tetanus prone. Wound Age Wound age is a critical factor in deciding whether a wound should undergo primary closure. A wound more than six hours old is considered a high risk for infection.
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