Compartment Syndrome

02/03/2010

condition in which compression of nerves, blood vessels and muscle inside a closed space (compartment) within the body.

  • Pathophysiology:
  • Edema results due to trauma that compresses and compromises surrounding and distal blood vessels, nerves and muscle.
  • Connective tissue that defines the compartment does not stretch
  • A small amount of bleeding into the compartment, or swelling of the muscles within the compartment, can cause the pressure to rise

 

Etiology:

following injury, surgery or in most cases repetitive and extensive muscle use

Below a list of common causation factors:

  1. fractures
  2. ischemic reperfusion following injury
  3. hemorrhage
  4. vascular puncture
  5. intravenous drug injection
  6. casts
  7. prolonged limb compression
  8. crush injuries
  9. burns

Treatment:

includes relieving pressure through incision and drainage

left untreated tissue necrosis, neuro, and vascular damage may result


Skin Integrity

08/12/2009


Wound Dressing Types

24/11/2009

Gauze

  Advantages: Readily available in many sizes and forms, gauze can be used on infected wounds and can be combined with other topical products. It’s effective for packing wounds with tunnels, tracts, or undermining.Disadvantages: Gauze must be held in place by a secondary dressing, and fibers may shed or adhere to the wound bed. Gauze dressings should be changed frequently—if it dries out, it may stick to the wound bed and disrupt wound healing. Gauze isn’t recommended for effective moist wound treatment or bacterial barrier. Although research supports moist wound healing, the old standard of wet-to-dry gauze dressings is still being used in some places.

Transparent film

Made of polyurethane or copolymer, this type of dressing has a porous adhesive layer that lets oxygen pass through to the wound and moisture vapor escape from the wound.Indications: Partial-thickness wounds, Stage I and II pressure ulcers, superficial burns, and donor sites. It also can be used as a secondary dressing.Advantages: This dressing doesn’t have to be removed when you examine the wound. Transparent film also is impermeable to external fluid and bacteria, promotes autolytic debridement, and prevents or reduces friction. Available in numerous sizes, it conforms to the body. Change the dressing every 5 to 7 days, or if it becomes soiled, wet, or starts to leak fluid.Disadvantages: The dressing may stick to some wounds. Most transparent dressings don’t absorb moisture and aren’t indicated for draining wounds. However, some of the newer transparent films have absorption properties. Fluid retention under the dressing may lead to periwound maceration. This dressing can’t be used on third-degree burns.

 

Foam

Nonadherent and nonocclusive, foam is an absorptive dressing consisting of hydrophilic polyurethane or film-coated gel.Indications: Stages II through IV pressure ulcers, partial- and full-thickness wounds with minimal to heavy drainage, surgical wounds, dermal ulcers, and under compression wraps. Check the package insert to determine if the product can be used in infected wounds or those with tunneling or sinus tracts.Advantages: Many sizes, shapes, and forms are available. Foam is conformable, easy to apply, and easy to remove because it’s nonadherent. The frequency of dressing changes depends on the amount of wound drainage.Disadvantages: A secondary dressing or tape may be needed to secure some of the first foam dressings. Newer versions have an adhesive border to help keep them in place. Foam isn’t recommended for nondraining wounds or dry eschar. Some foams can’t be used on infected wounds or those with tunneling or tracts. Always read the package insert to determine if you can use the product for a particular wound type. If not changed appropriately, foam dressings can let excess moisture accumulate, macerating periwound skin.

 

 

Composites

Manufactured as a single dressing, composites are combinations of two or more different products. Features may include a bacterial barrier, absorptive layer, foam, hydrocolloid, or hydrogel. The dressing may have semi-adherent or nonadherent properties.Indications: Use composites as primary and secondary dressings for partial- and full-thickness wounds, for minimally to heavily draining wounds, dermal ulcers, and surgical incisions. Check the package insert to see if the dressing is suitable for pressure ulcers.Advantages: Composites facilitate autolytic debridement, are conformable, and are available in many sizes and shapes. Most include an adhesive border, so they’re easy to apply and remove. Check the package insert for frequency of dressing change.Disadvantages: Some composite dressings are contraindicated for Stage IV pressure ulcers. The adhesive borders of composites may limit their use on fragile skin. Not all composite dressings provide a moist healing environment, so monitor frequently for desiccation.

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=762247


Wound Pain Assessment

14/11/2009

The Wounded Man

A wood cut – early trauma-medicine. first appearing in
Johannes de Ketham’s Fasciculus Medicinae, 1492.

 

 A battle map of the human body, showing the effects of what happened to that body when someone tried to erase its existence. It was accompanied by instructions on how to deal with all of the trauma, and to save the man thus that he could fight again. 

 

Wound Pain Assessment

  • wound pain impacts QoL and functioning
  • Pain or change in pain can be indicative of inflammation or infection

Note in Every Assessment:

  1. Location
  2. Frequency
  3. Onset
  4. Duration
  5. Intensity (Pain Scale)
  6. Exacerbating or relieving factors

Wound Pain can be divided into 3 categories

  1. Non-cyclic acute wound pain
  • occurs during manipulation of the wound (eg. Wound debridement)
  • local anesthetics can provide some relief

 2. Cyclic acute wound pain

  • accompanies regular procedures (dressing changes and repositioning)
  • non traumatic dressings, soaking dressing prior to removal and allowing pt to control procedures are pain minimization strategies.

 3. Chronic wound pain

  • persistently felt, even when wound is not being manipulated
  • medications can help control pain

Studies have shown:

“Trauma during dressing changes was again recognised to be caused by adherent products and drying out of dressings. Although gauze has a major traumatic effect during removal (Grocott, 2000), practitioners did not consider this cause of tissue trauma as an important issue. Perhaps this is because, contrary to best practice, some countries still advocate the use of wet to dry gauze dressings for debridement;

– The most common strategies to manage pain at dressing changes were to soak old dressings, choose non-traumatising dressings and select dressings that do not cause pain during removal. However, soaking dry dressings is contrary to recommendations and may compromise the current principles of moist wound healing (Hollinworth and Collier, 2000). In addition, involving patients in strategies to avoid pain and supporting the surrounding skin during removal were not considered important, despite evidence that adhesive wound care products lead to skin stripping and potential pain and skin trauma (Gotschall et al, 1998; Dykes et al, 2001);

– Only respondents from the UK and France considered giving analgesia before dressing change as an important factor. Respondents from Spain, Austria and Germany only ranked this as their last but one option, even though the prolonged inflammatory response in chronic wounds can lead to increased sensitivity in the wound and surrounding skin (Briggs and Torra i Bou, 2002);

 While research over the past decade has concentrated on wound healing and how this can be improved using evidence-based practice, studies repeatedly demonstrate that the pain of chronic wounds has a major impact on patients’ quality of life (Charles, 1995; Franks and Moffatt, 1998). In addition, wound pain and tissue trauma – especially at wound dressing changes – has been marginalised as an issue by health care professionals (Hollinworth, 1999).”

Hollinworth, Helen. 2002. How to alleviate pain at wound dressing changes. Nursing Times. 98 (44) 51.

Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier


Surgical Drains: Penrose and Jackson-Pratt

13/11/2009

Wound Drainage

  • Drain insertion into a wound is standard if a large amount of drainage is expected
  • Drains prevent fluid build up in the tissues which would slow healing and increase infection risk.
  • Drains may be sutured in place to maintain placement and integrity
  • Caution used upon changing wound dressings surrounding a drain site

The Penrose drain

 A soft rubber tube placed in a wound area, to prevent the build up of fluid.

 

 

  • This is the most commonly used drain
  • Made of flexible, soft rubber and causes little tissue reaction.
  • Acts by drawing any pus of fluid along its surfaces through the incision or through a stab wound adjacent to the main incision.
  • It has a large safety-pin outside the wound to maintain its position
  • To Facilitate drainage and healing of tissues from the inside to the outside, the tube is often pulled out and shortened 1-2 inches each day until it falls out.
  • The safety-pin should be placed in its new position prior to cutting the drain
  • Advance the drain with dressing forceps or hemostat, use surgical scissors to cut excess drain.
  • Note drainage amount and colour appearing in collection apparatus

The Jackson-Pratt, JP drain, or Bulb drain (Hemovac)

 

  • Consists of a flexible plastic bulb that connects to an internal plastic drainage tube
  • Device used to pull excess fluid from the body by constant suction.
  • Removing the plug and squeezing the bulb removes air
  • This is usually accomplished by folding the drain in half while it is uncapped, then while folded, recapping the drain.

 

Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier


Wound Healing Pathophysiology

12/11/2009

Phases of Wound healing

  1. Inflammatory Phase
  2. Proliferative Phase
  3. Remodelling Phase
  • duration of phases depends on the extent of injury and healing environment

 

Inflammatory Phase

  • inflammation occurs at time of injury
  • prepares wound environment for healing
  • blood vessel constriction
  • thrombus formation
  • vasodilation
  • increased capillary permeability
  • phagocyte emigration
  • digest debris
  • neutrophils arrive first, ingest bacteria, gone by day 3-4
  • macrophages appear 24hr after injury, remaining for an extended period
  • macrophages function in phagocytosis
  • macrophages release growth factors stimulating epithelial cells proliferation and angiogenesis
  • wounds may heal in absence of neutrophils, they cannot heal without macrophages

Proliferation Phase

  • begins within 2-3 days of healing
  • lasts up to 3wks
  • function – tissue building to fill wound space
  • fibroblasts produce collagen and other intracellular elements required for wound healing
  • 24-48hrs post injury fibroblasts and vascular endothelial cells begin proliferation of granular tissue (the foundation of scar tissue)
  • tissue is fragile and bleeds easily during to the # of newly formed capillary buds
  • in primary intention healing, epidermal cells seal the wound within 24-48h
  • epithelial cells require a moist surface for proliferation, therefore will wait to migrate under newly formed scab.
  • In cases of excessive granular tissue formation, re-epitheliarization may be impeded. Chemical cauterization may be required to allow healing to proceed
  • collagen synthesis peaks at 5-7days, continuing for several weeks

Remodelling Phase

  • 3 wks post injury, continuing 6 months or longer
  • cycle of collagen synthesis and collagenolysis
  • wound tensile strength increases
  • wounds will not regain original unwounded tensile strength
  • sutures provide 70% of tensile strength of non wounded skin
  • at suture removal 1 week post surgery, wound has only 10%
  • tensile strength increases to 70-80% over the next 4 wks before plateau

Factors Affecting wound healing

  1. Malnutrition
  2. blood flow & O2 delivery
  3. Impaired Inflammatory and Immune Response
  4. Infection, Wound separation and foreign bodies

Martin, Glenn and Porth, Carol, Mattson. 2009. Pathophysiology Concepts of Altered Health States. 8th ed. Lippincott Williams and Wilkins. Philadelphia