BSN – 4E Group 3

Mae Valerie BermudezNaldy John Delos SantosStephanie Marie LimKathreen Glaiza MendozaMichael SantosRizza Faith SasiDenise Marie Villanueva

Emergency Nursing

Thoracentesis

Thoracentesis (THOR-a-sen-TE-sis) is a procedure to remove excess fluid in the space between the lungs and the chest wall.

This space is called the pleural space.

Normally, the pleural space is filled with a small amount of fluid about 4 teaspoons full.

But some conditions, such as heart failure, lung infections, and tumors, can cause more fluid to build up.

When this happens, it’s called a pleural effusion.

A lot of extra fluid can press on the lungs, making it hard to breathe.

Overview Thoracentesis is done to find the cause of

a pleural effusion. It also may be done to help you breathe easier.

During the procedure, your doctor inserts a thin needle or plastic tube into the pleural space and draws out the excess fluid. Usually, doctors take only the amount of fluid needed to

find the cause of the pleural effusion.

However, if there's a lot of fluid, they may take more. This helps the lungs expand and take in more air, which

allows you to breathe easier.

After the fluid is removed from your chest, it's sent for testing.

Once the cause of the pleural effusion is known, your doctor will plan treatment.

For example, if an infection is causing the excess fluid, you may be given antibiotics to fight the infection.

If the cause is heart failure, you will be treated for that condition.

Thoracentesis usually takes 10 to 15 minutes.

It may take longer if there's a lot of fluid in the pleural space.

You will be watched for up to a few hours after the procedure for complications.

Outlook The procedure usually doesn't

cause serious problems, but some risks are involved.

• These include pneumothorax (noo-mo-THOR-aks), or collapsed lung; pain, bleeding, bruising, or infection where the needle or tube was inserted; and liver or spleen injury (very rare).

• Most of these complications get better on their own, or they're easily treated.

Who Needs Thoracentesis? You may need thoracentesis if you have a

pleural effusion. A pleural effusion is the buildup of

excess fluid in the pleural space (the space between the lungs and chest wall).

Thoracentesis helps find the cause of the pleural effusion.

It also may be done to help you breathe easier, if there's a lot of fluid in the pleural space.

The most common cause of a pleural effusion is heart failure.

This is a condition in which the heart can't pump enough blood to the body.

Other causes include lung cancer, tumors, pneumonia, tuberculosis, pulmonary embolism, and other lung infections.

Asbestosis, sarcoidosis, and reactions to some drugs also can lead to a pleural effusion.

Diagnosing a Pleural Effusion A pleural effusion is diagnosed based on your

medical history, a physical exam, and test results.

Medical History Your doctor will ask about your symptoms, like trouble breathing, coughing, and

hiccups. Other things your doctor may ask about

include whether you've ever: Had heart disease Smoked Traveled to places where you may have

been exposed to tuberculosis Had a job that exposed you to asbestos

Physical Exam Your doctor will listen to your breathing with a stethoscope and tap lightly on your chest. If you have a pleural effusion, your

breathing may sound muffled. There also may be a dull sound when

your doctor taps on your chest.

Diagnostic Tests Your doctor may use one or more of the following tests to

diagnose a pleural effusion.

1.Chest x ray. This test takes pictures of your heart and lungs. It may show air or fluid in the pleural space. It also may show what's causing the pleural effusion, such as pneumonia or a lung tumor. To get more detailed pictures, the x rays may be done while you're in different positions.

2. Ultrasound. This test uses sound waves to create pictures of your lungs. It may show where fluid is in your chest. Sometimes it's used to find the right place to insert the needle

or tube for thoracentesis.

3. Computed tomography (CT) scan.

This test provides a computer-generated picture of the lungs that can show pockets of fluid.

It may show fluid when a chest x ray doesn't.

It also may show signs of pneumonia or a tumor.

Before Thoracentesis Before thoracentesis, your doctor will talk to you about the procedure and how to prepare for it. Tell your doctor what medicines you're

taking, about any previous bleeding problems, and about allergies to medicines or latex.

No special preparations are needed before thoracentesis.

During Thoracentesis Thoracentesis is done at a doctor's office

or hospital. The entire procedure (including

preparation) usually takes 10 to 15 minutes, but the needle or tube is in your chest for only a few minutes during that time.

If there's a lot of fluid, the procedure may take up to 45 minutes.

You will sit on the edge of a chair or exam table, lean forward, and rest your arms on a table.

Your doctor will tell you not to move, cough, or breathe deeply once the procedure begins.

He or she cleans the area of your skin where the needle or tube will be inserted and injects medicine to numb the area.

You may feel some stinging at this time.

Your doctor then inserts the needle or tube between your ribs and into the pleural space (the area between the lungs and chest wall).

You may feel some discomfort and pressure at this time.

Your doctor may use ultrasound to find the right place to insert the needle or tube.

•He or she then draws out the excess fluid around your lungs using the needle or tube. •You may feel like coughing, and you may feel some chest pain. •If a lot of fluid is removed, your lungs will have more room to fill with air as the fluid is drawn out. •This can make it easier to breathe.

After Thoracentesis After the procedure, you will be

monitored until your blood pressure, pulse, and breathing are stable.

If the procedure was done at the bedside, you will remain in your hospital room.

If the procedure was performed on an outpatient basis, you will be discharged to your home, unless your physician decides otherwise.

•If the procedure was performed on an outpatient basis, you should plan to have another person drive you home.•The dressing over the puncture site will be monitored for bleeding or other drainage.

You will be positioned in a side-lying position with the unaffected side down for an hour or longer.

You may have a chest x-ray performed after the procedure.

When the recovery period is over, you may resume your usual diet and activities unless your physician advises you differently.

Notify your physician to report any of the following:

1.fever and/or chills2.redness, swelling, or bleeding or other drainage

from the puncture site3.difficulty breathing

4.Your physician may give you additional or alternate instructions after the procedure,

depending on your particular situation.

Paracentesis

Procedure Name: Paracentesis Description: It is the removal of fluid(ascites) from the

peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions.

Synonyms: Abdominal Paracentesis; Ascites Fluid Tap Procedure Commonly Includes: At the bedside, physician introduces a needle

into the peritoneal space of a patient with free ascites, and samples the fluid for diagnostic and/or therapeutic purposes.

Indications patients with new onset of ascites ascites fluid of unknown etiology patients with clinically suspected ascites fluid infections (abdominal pain, unexplained fever,

leukocytosis, declining mental status) Lastly therapeutic paracentesis is

indicated when ascites fluid has accumulated enough to cause respiratory compromise, abdominal pain, or worsening of existing inguinal or umbilical hernias.

Contraindications Severe coagulopathy not correctable by

vitamin K, fresh frozen plasma, etc; inability of physician to demonstrate ascites fluid on physical examination; lack of patient cooperation.

Recent literature suggests the following factors are not contraindications for paracentesis: morbid obesity, low grade coagulopathy, multiple abdominal surgical

scars, and bacteremia.

Patient Preparation Technique and risks of the

procedure are explained. Premedications (eg, sedatives or

narcotics) are not routinely required. Laboratory requisitions are

completed in advance to avoid delay in fluid processing later.

•Prothrombin and partial thromboplastin times prior to paracentesis are ordered at physician discretion (some elect to transfuse fresh frozen plasma immediately prior to procedure if PT/PTT are prolonged).

Preprocedure Check for signed consent form Prepare the patient by providing the necessary information and instructions Instruct the patient to void Gather appropriate sterile equipment and collection receptacles Place the patient in upright position on the edge of the bed or in a chair w/ feet supported on a stool. Fowler's position should be used by the patient confined to bed. Place the sphygmomanometer cuff around patient's arm.

Procedure The physician, using aseptic technique,

inserts the trocar through a puncture below the umbilicus.

The trocar or needle is connected to a drainage tube, the end of w/c is inserted into a collecting receptacle.

Help the patient maintain position throughout the procedure.

Measure and record blood pressure at frequent intervals throughout the procedure.

Monitor the patient closely for signs of vascular collapse: pallor, increased pulse rate, or decreased blood pressure.

Postprocedure Return patient to bed or to a comfortable sitting

postion Measure, describe, and record the fluid

collected. Label samples of fluid and send to laboratory. Monitor vital signs every 15 min for 1h, every 30

min for 2h, every hour for 2h, and then every 4h. Measure the patient's temperature. Assess for hypovolemia, electrolyte shifts,

changes in mental status and encephalopathy. When taking vital signs, check puncture site for

leakage or bleeding. Provide patient teaching regarding need to

monitor for bleeding or excessive drainage from puncture site.

Abscess Incision and Drainage

Abscesses are localized infections of tissue marked by a collection of pus surrounded by inflamed tissue.

Abscesses may be found in any area of the body, but most abscesses presenting for urgent attention are found on the extremities, buttocks, breast, perianal area, or from a hair follicle.

Abscesses begin when the normal skin barrier is breached, and microorganisms invade the underlying tissues. Causative organisms commonly include Streptococcus, Staphylococcus, enteric bacteria (perianal abscesses), or a combination of anaerobic and gram-negative organisms.

Abscess resolve by drainage. Smaller (<5mm in diameter) abscesses may resolve to conservative measures (warm soaks) to promote drainage.

• Larger abscesses will require incision to drain them, as the increased inflammation, pus collection, and walling off of the abscess cavity diminish the effectiveness of conservative measures.

Contraindications Extremely large abscesses which

require extensive incision, debridement, or irrigation (best done in OR)

Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) which require a general anesthetic to obtain proper exposure

Palmar space abscesses, or abscesses in the deep plantar spaces

Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a septic phlebitis)

IndicationsAbscess on the skin which is palpable

Materials Universal precautions materials 1% or 2% lidocaine WITH epinephrine for

local anesthesia, 10 cc syringe and 25 gauge needle for infiltration

Skin prep solution #11 scalpel blade with handle Draping Gauze Hemostat, scissors, packing (plain or

iodoform, 1/2”) Tape Culture swab

Preprocedure Education

Obtain informed consent Inform the patient of

potential severe complications and their treatment

Explain the steps of the procedure, including the not insignificant pain associated with anesthetic infiltration

Explain necessity for follow-up, including packing change or removal

Procedure Use universal precautions Cleanse site over abscess

with skin prep Drape to create a sterile

field Infiltrate local anesthetic,

allow 2-3 minutes for anesthetic to take effect

Incise widely over abscess with the #11 blade, cutting through the skin into the abscess cavity. Follow skin fold lines whenever able while making the incision

Allow the pus to drain, using the gauzes to soak up drainage and blood. Use culture swab to take culture of abscess contents, swabbing inside the abscess cavity

Use the hemostat to gently explore the abscess cavity to break up any loculations within the abscess

Using the packing strip, pack the abscess cavity

Place gauze dressing over wound, and tape in place

Postprocedure Much of the pain around an abscess will be

gone after the surgery. Healing is usually very rapid. After the drainage tube is removed,

antibiotics may be continued for several days.

Applying heat and keeping the affected area elevated may help relieve inflammation.

Complication

Prevention Management

Insufficient anesthesia

Remember that the tissue around

an abscess is acidotic, and local anesthetic loses effectiveness in acidotic tissues

Do a field block; use sufficient quantity of

anesthetic; allow time for

anesthetic effect

No drainage Localize site of incision by palpation

Extend incision deeper or wider

as neededDrainage is sebaceous material

Abscess was an inflamed

sebaceous cyst

Express all material, break

up sac with hemostat, pack open as with an

abscess

Surgical Excision

Why do skin lesions have to be excised? A common reason why skin lesions are

excised, is to fully remove skin cancers such as basal cell carcinoma, squamous cell carcinoma or melanoma. If the cancer is not cut out it may spread to the surrounding skin and to other parts of the body (metastasise).

Other reasons that skin lesions are excised include cosmetic appearance, to remove an inflamed cyst, or recurrent infection.

DEFINITIONSurgical excision is the removal of tissue by a doctor or surgeon using a scalpel (sharp knife) or other cutting instrument.

What is involved in excision of a skin lesion? Your dermatologist will explain to you why the

skin lesion needs excision and the procedure involved.

You may have to sign a consent form to indicate that you consent to the surgical procedure.

•Tell your doctor if you are taking any medication (particularly aspirin or warfarin, which could make you bleed more), or if you have any allergies or medical conditions. •Remember, to tell your doctor about any herbal remedies as a number of these can also lead to abnormal bleeding.

The most common type of excision is an elliptical excision.

The ellipse is designed so that the resulting scar runs parallel with existing skin creases.

This ensures that the scar is as narrow and short as possible.

• The area to be excised is marked with a coloured pen. • The dermatologist will then cut around and under the lesion with a scalpel and sharp scissors so that it is completely removed. • The lesion is placed in formalin ready to go to the pathology laboratory.

Here, a pathologist will examine the specimen and provide your doctor with a report a few days later.

There may be some bleeding in the area from where the lesion has been removed.

The doctor may coagulate the blood vessels with a diathermy.

This can make a hissing sound and a burning smell.

The edges of the ellipse will then be sewn together to make a thin suture line.

There may be two layers of sutures (stitches) a layer underneath that is absorbable and a layer of sutures on the surface which will need to be removed in 4-14 days.

•Occasionally special skin glue is used to join the edges together, instead of sutures. •A dressing may be applied and instructions should be given on how to care for your wound and when to get the stitches out.

How do I look after the wound following skin excision?

Your wound may be tender 1-2 hours after the excision when the local anaesthetic wears off.

Leave the dressing in place for 24 hours or as advised by your dermatologist.

•Avoid strenuous exertion and stretching of the area until the stitches are removed and for some time afterwards. •If there is any bleeding, press on the wound firmly with a folded towel without looking at it for 20 minutes.

Keep the wound dry for 48 hours. You can then gently wash and dry the wound.

If the wound becomes red or very painful, consult your dermatologist - it could be infected.

• The scar will initially be red and raised but usually reduces in colour and size over several months.

Open and Closed Wounds

An open wound is a break in the skin’s surface resulting in external bleeding.

It may allow bacteria to enter the body, causing an infection.

1. Abrasion The top layer of

skin is removed, with little or no blood loss.

2. Laceration Is cut skin with

jagged, irregular edges.

Caused by a forceful tearing of skin tissue.

3. Incisions Have smooth edges

and resemble a surgical or paper cut.

4. Punctures Usually deep,

narrow wounds in the skin and underlying organs such as stab from a nail or a knife.

5. Avulsion A piece of skin is

torn loose and is hanging from the body or completely removed.

6. Amputation Involves the cutting

or tearing off of a body part.

Protect yourself against disease. Expose the wound by removing or

cutting away the clothing to find the source if bleeding.

Control the bleeding by using direct pressure.

If needed, use other method.

Scrub your hands. Expose the wound. Clean the wound (next slide). Remove small objects not flushed out

with sterile tweezers. If bleeding restarts, apply direct

pressure over the wound.

For a shallow wound: Wash inside the wound with soap and

water. Flush the wound with running water.

For a wound with high risk of infection: Seek medical care. Clean the wounds as best as you can.

For small wound: Cover it with a thin layer of antibiotic

ointment. Cover the wound with sterile dressing. If a wound bleeds after dressing has been

applied and the dressing becomes stuck, leave it on as long as the wound is healing.

If dressing becomes wet or dirty, change it.

When to Seek Medical Care:When to Seek Medical Care: Embedded foreign material Animal and human bites Puncture wounds Large or deep wounds Wound where edges do not come

together Visible bone, joint, muscle, fat, or

tendons

Happens when a blunt object strikes the body.

The skin is not broken, but tissue and blood vessels beneath the skin’s surface are crushed, causing bleeding within a confined area.

1. Contusions more commonly

known as bruises, caused by blunt force trauma that damages tissue under the skin.

2. Hematomas also called blood

tumors, caused by damage to a blood vessel that in turn causes blood to collect under the skin.

Control bleeding by applying an ice pack over the area >20 minutes

For extremities, apply an elastic bandage for compression

Check for a possible fracture Elevate an injured extremity to

decrease the pain and swelling

Bone Fractures

• A broken bone (fracture) occurs when a force exerted against bone is stronger than the bone can structurally withstand.

• Bones are a form of connective tissue, reinforced with calcium and bone cells.

• Bones have a softer centre, called marrow, where blood cells are made.

• The main functions of the skeleton include support, movement and protection of vulnerable internal organs.

There are different types of bone fractures that vary in severity. Factors that influence severity include

the degree and direction of the force, the particular bone involved, and the person's age and general health.

Common sites for bone fractures include the wrist, ankle and hip.

• Hip fractures occur most often in elderly people. • Broken bones take around four to eight weeks to heal, depending on the age, health of the individual, and the type of break.

SymptomsThe symptoms of a bone fracture depend on

the particular bone and the severity of the injury, but may include:

Pain, with sweating and a pale face Swelling Bruising Deformity Inability to use the limb.

1. Greenstick fracture

the bone sustains a small, slender crack. This type of fracture is more common in children, due to the comparative flexibility of their bones.

2.Comminuted fracture

the bone is shattered into small pieces. This type of complicated fracture tends to heal at a slower rate.

3.Simple fracture

The broken bone hasn't pierced the skin.

4. Compound fracture

The broken bone juts through the skin, or a wound leads to the fracture site. The risk of infection is higher with this type of fracture.

5. Pathological fracture

bones weakened by various diseases (such as osteoporosis or cancer) tend to break with very little force.

6. Avulsion fracture muscles are

anchored to bone with tendons, a type of connective tissue. Powerful muscle contractions can wrench the tendon free, and pull out pieces of bone. This type of fracture is more common in the knee and shoulder joints.

7.Compression fracture

occurs when two bones are forced against each other. The bones of the spine, called vertebrae, are prone to this type of fracture. Elderly people, particularly those with osteoporosis, are at increased risk.

Recognizing Fractures It may be difficult to tell if a bone is

broken. When in doubt, treat the injury as a fracture.

Assess for D-O-T-S Deformity

Open wound Tenderness

Swelling

Care for Fractures: Expose and examine the injury site.

Bandage any open wound. Splint the injured area. Apply ice or cold pack.

Seek medical care or Call 9-1-1. Transport victim if necessary.

Reduction of Fractures

Reduction It is the positioning a bone or bones to their

normal position after a fracture or dislocation. The goals of a reduction are to restore

position (alignment, rotation, and length) to the bone or joint, to decrease pain, to prevent later deformity, and to encourage healing and normal use of the bone and limb.

In the case of a fracture, it is also important for the bone ends to meet correctly (apposition). If a fracture is described as "non-displaced" or in "anatomic position," no reduction maneuver to improve position can be performed, since the fracture is already in perfect position.

Also, this is the correct approximation of the broken portions (fragments) of the bone. There are two types of reduction namely:

Closed Reduction (External Fixation)• In closed reduction (external fixation), the

fracture is realigned to normal position through external manipulation of the part.

• Closed reduction is accomplished under x- ray control to be certain that the fracture is in correct position.

• Closed reduction is the method by which closed fractures are reduced most commonly.

• Then the alignment is maintained by immobilizing the part by either of two methods.

(1)  A plaster cast may be applied to hold the fragments in correct alignment after a fracture has been reduced.

(2)  The other method of external fixation is the application of skeletal traction by means of special pins or wire inserted through the soft tissue into bone that is distal to the fracture.

Open Reduction (Internal Fixation). • This is the reduction of a fracture by the application of mechanical devices (see figure 5-1) (screws, plates and screws, pins, intramedullary nails) through an incision directly to the bone.

EFFECTS OF CLOSED REDUCTION FRACTURE

With this procedure, the bone should heal in a normal position and the patient will regain the use of the bone and the limb it serves.

The pain from the broken bone will be relieved with this procedure.

CANDIDATES FOR CLOSED REDUCTION FRACTURE

A closed reduction procedure is recommended if your bone is broken in one place and has not broken the skin and you do not need plates, pins, or screws put in the bone to help hold it in place.

THE PROCEDURE: Closed reduction of a fracture involves

manipulation of a fracture or dislocation without open surgery in order to realign broken or dislocated bones so that the ends meet, thereby facilitating the healing process.

• It is the most common type of fracture treatment, because most broken bones can heal successfully once they have been repositioned and a cast has been applied to keep the broken ends in proper position while they heal.

RECOVERY A hospital stay is not necessary. You may go home later in the day

depending on how you are doing.

It is likely that you may have a splint, dressing or cast to help keep the bone in place during the healing process. Talk to your health care provider and ask what steps you should take and when you should return for a check-up.

RISKS Aside from the risks of general

anesthesia, there are other complications with this procedure.

For one, the bone may grow together in a different way than it was originally and may not be perfectly lined up.

There may also be a loss of feeling in the area of the break if a nerve is damaged. And if an artery is near the fracture, it could be damaged too.

Once the correct position has been attained, the affected area is put into a cast or traction to ensure immobility.

Sedation or some form of anesthesia is usually used during the procedure.

BENEFITS You might receive the following benefits.

The doctors cannot guarantee you will achieve any of these benefits. Only you can decide if the benefits are worth the risk. Results depend upon the extent of damage to the bone and the location of the bone itself; if successful, there may be:

Complete healing Reduced pain

Improved alignment of the fracture fragments

This procedure is used to repair broken fragments by means of pins, nails, and screws, or with plates and screws, through an open wound.

A blind method of fixation may be used by applying a short nail (Smith-Petersen) or a long nail (Kuntscher or Lottes) through the bone without opening the fracture site.

• Internal fixation is used when a satisfactory closed reduction cannot be obtained or maintained or when soft parts are situated between the fractured fragments. • Whenever possible, this operation is done before swelling has occurred or after swelling has subsided. It is not routinely done in the presence of an infection.

An open reduction or open reduction, internal fixation (ORIF) is done when a closed reduction is not possible or when the fracture is complicated by a wound.

This is an in-patient or outpatient surgical procedure performed in the operating room.

An incision is made over the fracture, wounds are cleaned, and the fracture position is corrected with pressure.

Sometimes the reduced position is maintained with orthopedic hardware such as screws, plates and rods, placed through or around the fracture fragments (internal fixation).

An external fixator device may be used to maintain position.

The fixator is composed of pins or rods through the skin and bone, and the free end of the rods are then attached to a long bar on the outside of the skin.

•This device can allow for early motion of the joints above and/or below the fracture. •It is always eventually removed, often in the physician's office, while internal hardware may be left in place. •If internal hardware is to be removed, another surgical procedure is required.

The outcome of a closed or open reduction depends on the type of injury and the treatment needed to maintain the reduction and the healing of bone and supporting tissue (joint capsule, tendons, ligaments, and muscles).

Generally, fractures and dislocations can be re-positioned (reduced) but this may not always be a simple, straightforward procedure.

•Once the reduction is complete, the healing phase may involve treatment over several months. •Any complication regarding nerves or blood vessels will delay healing and may contribute to a poor outcome.

For fractures that involve joints (intra-articular fractures), the more comminuted (broken into multiple fracture pieces) the joint surface and the greater joint surface deformity present after the fracture has healed, the worse the prognosis for the development of late post-traumatic arthritis of the joint.

• Fractures that do not involve joints but that heal with significant deformity change biomechanics of the limb and may lead to post-traumatic arthritis of adjacent joints.

Some bones such as those in the wrist (scaphoid and lunate) and hip (femoral head) have a poor blood supply to begin with and historically do not heal well.

Individuals with loose tissue (laxity) have a higher incidence of recurrent dislocation, as do those with anatomical variations such as tilted kneecaps (patellar misalignment). Joints that remain dislocated for a long time

have a less successful outcome.

Bone Grafting

This procedure involves exposure of the fractured fragments, attachment of healthy bone onto the bone fragments, and insertion of screws through holes made in the graft and into the cortex of the fragments.

• The amount of grafting material used and the type of graft done generally depends on the location of the non-united bone, the condition of the ends of the fragments, and the preference of the surgeon.

The procedure may be used in the following circumstances:

(1)  To fill cavities or defects resulting from cysts, tumors, or other causes.

(2)  To bridge joints and thereby provide arthrodesis.

(3)  To bridge major defects or establish the continuity of a long bone.

(4)  To promote union or fill defects in delayed union, malunion, fresh fractures, or osteotomies.

Operative Procedure(1)  The skin overlying the fractured bone is

incised and the scar tissue is excised, as in open reduction.

To encourage healing, the sclerosed bone may be drilled or removed to stimulate granulation tissue foundation.

(2)  The graft is obtained, and the affected fragments are prepared to suit the graft.

To form a bed for an onlay graft, the periosteum and a portion of the outer cortex are removed from the fragmented ends of the bone.

To perform an inlay or sliding graft, a special slot is made in the bone fragments for the reception of the graft.

Occasionally, a sliding graft is used for tibial fractures.

The graft is cut from the proximal fragment of the fractured bone and is slid into the prepared bed over the distal fragment of the bone.

(3)  To obtain an inlay graft from the tibia, a curved incision is made along the anteromedial surface of the tibia, with its convexity to the medial side.

The periosteum is incised and reflected with an osteotome.

The graft is outlined with drill holes, and removed with an electric oscillating bone saw that has a double blade.

A fracture of the entire thickness of the donor bone may occur if the osteotomy is not outlined by drill holes.

(4)  In an onlay grafting operation, bone-holding forceps are used on the operative site as the drill holes are placed through both the graft and fragments.

Screws are then inserted through the holes of the graft and into the cortex of the bone's fragments. In some cases, bone chips are laid over the fragments to be united.

(5)  A cancellous graft consists of spongy bone, usually taken from the crest or wing of the ilium.

Depending on the position of the patient, the anterior or posterior third of the ilium is used.

Exposure of the ilium is relatively easy, but considerable bleeding may occur.

An incision is made along the subcutaneous border of the iliac crest.

The muscles on the outer table of the ilium are elevated. If chip grafts are required, they are removed with an osteotome parallel to the crest of the ilium. After removal of the crest, the cancellous bone maybe obtained by curetting the cancellous space between the two intact cortices.

(6)  The wounds are closed in layers and dressings applied. A plaster casing may be applied to the fractured extremity.

Chest Thoracostomy Tube

DESCRIPTION Chest tubes are inserted to drain blood, fluid,

or air and to allow the lungs to fully expand. The tube is placed between the ribs and into

the space between the inner lining and the outer lining of the lung (pleural space).

The area where the tube will be inserted is numbed (local anesthesia). Sometimes sedation is also used.

The chest tube is inserted through an incision between the ribs into the chest and is connected to a bottle or canister that contains sterile water.

Suction is attached to the system for drainage. A stitch (suture) and adhesive tape keep

the tube in place. The chest tube usually stays in place until

the x-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. When the chest tube is no longer needed,

it can be easily removed. Most people don't need medications to

sedate or numb them while the chest tube is removed.

Antibiotics may be used to prevent or treat infection. In certain people, the chest tube may

be inserted using a minimally invasive technique guided by x-ray.

Sometimes chest tubes are placed during major lung or heart surgery while the person is under general anesthesia.

Why the Procedure is performed? Chest tubes are used to treat

conditions that can cause the lung to collapse, such as:

Air leaks from the lung into the chest (pneumothorax)

• Bleeding into the chest (hemothorax) • After surgery or trauma in the chest (pneumothorax or hemothorax) • Lung abscesses or pus in the chest (empyema).

INDICATIONS Tube thoracostomy is indicated for

pneumothorax, hemothorax, pleural effusion, empyema, and chylothorax. Timing, position, and relative indications will vary with each patient and must be individualized

CONTRAINDICATIONS Tube thoracostomy is contraindicated in

the absence of a pleural space (pleural symphysis).

Coagulopathy is a relative contraindication in elective settings.

MATERIALS 1. Chest tube; OR Fuhrman catheter 2. Chest tube suction unit (PleurevacR),

tubing, wall suction hookup 3. Chest tube tray to include scalpel blade

and handle, large Kelly clamps, needle driver, scissors

4. Packet of 0 or 1.0 silk suture on a curved needle

Tape, gauze 2% lidocaine with epinephrine, 20 cc

syringe, 23-gauge needle for infiltration Sterile prep solution; Mask, gown and gloves

PREPROCEDURE PATIENT EDUCATION 1. Obtain informed consent 2. Inform the patient of the possibility of

major complications and their treatment 3. Explain the major steps of the

procedure, and necessity for repeated chest radiographs

PROCEDURE 1. Examine the patient and assess need for

placement of a thoracostomy tube. Obtain pre-procedure chest X-ray

VERIFY SITE OF INSERTION!!!!!!2. Select site for insertion: mid-axillary line,

between 4th and 5th ribs…this is usually on a line lateral to the nipple

3. Don mask, gown and gloves; 4.Prep and drape area of insertion. Have patient

place ipsilateral arm over head to “open up” ribs5. Widely anesthetize area of insertion with the 2%

lidocaine. Infiltrate skin, muscle tissues, and right down to pleura

CHEST TUBE INSERTION   After infiltrating insertion site with local

anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins

INCISING THE CHEST WALLINSERTION 

-Continue incision through the intercostal muscles, and right down to the pleura

-Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this “creates” a pneumothorax, and allows the lung to fall away from the chest wall somewhat

OPENING THE INCISION WITH KELLYINSERTION 

Insert finger through your incision and into the thoracic cavity.

Make sure you are feeling lung (or empty space) and not liver or spleen

-Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura.

After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in

USING A KELLY TO GUIDE INSERTIONINSERTION 

-Clamp outer tube end with Kelly -Suture and tape tube in place -Attach tube to suction unit -Obtain post procedure chest Xray for

placement; Tube may need to be advanced or withdrawn slightly

COMPLICATIONS, PREVENTION, AND MANAGEMENT  

1. Puncture of liver or spleen. This is entirely preventable; Insertion site is in the nipple line, between 4th and 5th ribs!

2. Bleeding; This usually ceases3. Cardiac puncture. Again preventable,

carefully control the tube going in, DO NOT USE TUBES WITH TROCARS

4. Passage of tube along chest wall instead of into chest cavity.In this case, widen and deepen the dissection between the ribs, and make sure the insertion of the tube follows this path

ITEMS FOR EVALUATION OF PERSON LEARNING THIS PROCEDURE  

1. Anatomy of the chest, lungs, pleura2. Indications, and contraindications of this

procedure3. Use of sterile technique and universal

precautions4. Technical ability5. Appropriate documentation6. Understanding of potential complications

and their correction 

RISKS: Risks for any anesthesia are:

Reactions to medications Problems breathing

Risks for any surgery are: Bleeding Infection

Outlook (Prognosis) Most people completely recover from the

chest tube insertion and removal. There is only a small scar.

RECOVERY You will stay in the hospital until the

chest tube is removed. While the chest tube is in place, the

nursing staff will carefully check for possible air leaks, breathing difficulties, and the need for additional oxygen.

You'll need to breathe deeply and cough often to help re-expand the lung, assist with drainage, and prevent fluids from collecting in the lungs.

Casting and Debridement

WHAT IS A CAST? A cast holds a broken bone in

place as it heals. Casts also help to prevent or

decrease muscle contractions, and are effective at providing immobilization, especially after surgery.

Casts immobilize the joint above and the joint below the area that is to be kept straight and without motion.

For example, a child with a forearm fracture will have a long arm cast to immobilize the wrist and elbow joints.

WHAT ARE CASTS MADE OF? The outside, or hard part of the cast, is made from

two different kinds of casting materials. plaster - white in color. fiberglass - comes in a variety of colors,

patterns, and designs. Cotton and other synthetic materials are used to

line the inside of the cast to make it soft and to provide padding around bony areas, such as the wrist or elbow.

Special waterproof cast liners may be used under a fiberglass cast, allowing the child to get the cast wet.

Consult your child's physician for special cast care instructions for this type of cast.

WHAT ARE THE DIFFERENT TYPES OF CASTS? Below is a description of the various types of

casts, the location of the body they are applied, and their general function.

Short arm cast: Applied below the elbow to the hand. Forearm or wrist fractures. Also used to hold the

forearm or wrist muscles and tendons in place after surgery.

Long arm cast: Applied from the upper arm to the hand. Upper arm, elbow, or forearm fractures.

Also used to hold the arm or elbow muscles and tendons in place after surgery.

Arm cylinder cast:Applied from the upper arm to the wrist.To hold the elbow muscles and tendons in place after a dislocation or surgery.

Shoulder spica cast: Applied around the trunk of the body to the

shoulder, arm, and hand. Shoulder dislocations or after surgery on the

shoulder area.

Minerva cast:Applied around the neck and trunk of the body.After surgery on the neck or upper back area.

Short leg cast: Applied to the area below the knee to the

foot. Lower leg fractures, severe ankle

sprains/strains, or fractures. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing.

Leg cylinder cast:Applied from the upper thigh to the ankle.Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area.

Unilateral hip spica cast: Applied from the chest to the foot on one

leg. Thigh fractures. Also used to hold the hip or

thigh muscles and tendons in place after surgery to allow healing.

One and one-half hip spica cast:Applied from the chest to the foot on one leg to the knee of the other leg. A bar is placed between both legs to keep the hips and legs immobilized.Thigh fracture. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.

Bilateral long leg hip spica cast: Applied from the chest to the feet. A bar is placed

between both legs to keep the hips and legs immobilized.

Pelvis, hip, or thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.

Short leg hip spica cast: Applied from the chest to the thighs or knees. To hold the hip muscles and tendons in place

after surgery to allow healing.

Abduction boot cast: Applied from the upper thighs to the feet.

A bar is placed between both legs to keep the hips and legs immobilized.

To hold the hip muscles and tendons in place after surgery to allow healing.

How can my child move around while in a cast?

Assistive devices for children with casts include:

crutches walkers wagons wheelchairs reclining wheelchairs

Cast care instructions: Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges can be padded to protect the

skin from scratches. Do not scratch the skin under the cast by

inserting objects inside the cast. Can use a hairdryer placed on a cool

setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.

Do not put powders or lotion inside the cast. Cover the cast while your child is eating to prevent

food spills and crumbs from entering the cast. Prevent small toys or objects from being put inside

the cast. Elevate the cast above the level of the heart to

decrease swelling. Encourage your child to move his/her fingers or

toes to promote circulation. Do not use the abduction bar on the cast to lift or

carry the child.

Older children with body casts may need to use a bedpan or urinal in order to go to the bathroom.

Tips to keep body casts clean and dry and prevent skin irritation around the genital area include the following:

Use a diaper or sanitary napkin around the genital area to prevent leakage or splashing of urine.

Place toilet paper inside the bedpan to prevent urine from splashing onto the cast or bed.

Keep the genital area as clean and dry as possible to prevent skin irritation.

When to call your child's physician: Contact your child's physician or

healthcare provider if your child develops one or more of the following symptoms:

fever greater than 101° F increased pain increased swelling above or below the

cast complaints of numbness or tingling drainage or foul odor from the cast cool or cold fingers or toes

Debridement is the medical removal

of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthytissue. Removal may be surgical, mechanical, chemical, autolytic(self-digestion), and by maggot therapy, where certain species of live maggots selectively eat only necrotic tissue.

Autolytic Debridement: Description: Autolysis uses the body's own enzymes and

moisture to re-hydrate, soften and finally liquefy hard eschar and slough.

Autolytic debridement is selective; only necrotic tissue is liquefied. It is also virtually painless for the patient.

• Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. • Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films.

Best Uses: In stage III or IV wounds with light to

moderate exudate

Disadvantages: Not as rapid as surgical debridement Wound must be monitored closely for signs of infection May promote anaerobic growth if an occlusive hydrocolloid is used

Advantages: Very selective, with no damage to surrounding skin. The process is safe, using the body's own defense mechanisms to clean the wound of necrotic debris. Effective, versatile and easy to perform Little to no pain for the patient

Enzymatic Debridement: Description: Chemical enzymes are fast acting

products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not.

Best Uses: On any wound with a large amount of necrotic debris. Eschar formation

Advantages: Fast acting Minimal or no damage to

healthy tissue with proper application.

Disadvantages: Expensive Requires a prescription Application must be performed carefully only to the necrotic tissue. May require a specific secondary dressing Inflammation or discomfort may occur

Mechanical Debridement: Description: This technique has been used for decades in

wound care. Allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non-selective debridement.

Hydrotherapy is also a type of mechanical debridement. It's benefits vs. risks are of issue.

Best Uses: Wounds with moderate amounts of necrotic debris

Disadvantages: Non-selective and may traumatize

healthy or healing tissue Time consuming Can be painful to patient Hydrotherapy can cause tissue

maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting additives may be cytotoxic.

Advantages: Cost of the actual material (ie. gauze) is low

Surgical Debridement: Description: Sharp surgical debridement and laser debridement

under anesthesia are the fastest methods of debridement.

They are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind

Surgical debridement can be performed in the operating room or at bedside, depending on the extent of the necrotic material.

Best Uses: Wounds with a large amount of necrotic tissue. In conjunction with infected tissue.

Advantages: Fast and Selective Can be extremely effective

Disadvantages: •Painful to patient •Costly, especially if an operating room is required •Requires transport of patient if operating room is required.

Maggots Debridement Maggot therapy (also known as

maggot debridement therapy (MDT), larval therapy, larva therapy, larvae therapy, biodebridement or biosurgery) is a type of biotherapy involving the intentional introduction by a health care practitioner of live, disinfected maggots(fly larvae) raised in special facilities into the non-healing skin and soft tissue wound(s) of a human or animal for the purposes of selectively cleaning out only the necrotic tissue within a wound (debridement), disinfection, and promotion of wound healing.