nursing care in plastic surgery

7/31/2019 Nursing Care in Plastic Surgery

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Jeng-Yee Lin MD PhD

Division of Plastic Surgery, Taipei MedicalUniversity Hospital nad Taipei Medical University

Nursing care in Plastic Surgery



Wound healing process:

Hemostasis phase

Inflammatory phase

Proliferation phase

Scar Remodeling

Wound Healing



Vasoconstriction

Platelet aggregation PDGF

Coagulation cascade reaction

Hemostasis (0-3hr)



1.Neutrophil infiltration due to cytokine releaseswelling,

vasodilatation, and pain

2.Macrophage migration kill bacteria, debris

Inflammatory phase (0-3day)



Granulaton tissueNeoangiogenesis

Wound contraction

Epithelialization

Proliferation phase (3-21 day)



Procollagen sysnthesis

Collagen/fibril deposition

Collagen remodeling/maturation scar maturation

Wound strength increased

Remodeling phase (21day~)



Suture/wound closure

Skin graft

Local flap

Pedicle flapTissue expander

Free flap

Reconstructive ladder/ principle



Biological wound dressing:

Autograft skin: STSG FTSG;

xenograft skinSynthetic wound dressing

Sugical wound dressing



Skin grafts:

FTSG

STSG

Flaps:local flap, pedicle flap, free flap

Autologous tissue coverage



Open wound dressing: used in infected

wounds; adequate draining of the exudate;

promote mechanical debridement.

Closed wound dressing: promote woundhealing, autolytic wound debridement, and

granulation growth; can not be used in infected

wound, or dirty wound

Surgical wound dressing



VAC-negative pressure dressing:

promote cell cycle and granulation tissue

growth.continue draining of exudate of the wound.

avoid its use in malignancy.

Wound dressing



Foam: polyurathane film or porous sponge.

Hydrogel: water 70-90%, alternative to wet dressing.

Hyrocolloid: Duoderm, Comfeel,Alleyvn, slowly

absorbing water.Calcium alginate: promote hemostasis

Collagen-base bilayer skin substitute: Biobrane,

Integra

Silver containing dressing: Ag coated high densisty

Wound dressing



1.Synthetic dressing:

Hydrocolloid,CMC,

2.Biologic dressing: collagen/matrix base

(bovine)



Initial fluid resuscitation: Parkland formula

4 x burn area (%) x body weight (kg)

Half in initial 8 hr with crystalloid/ LactatedRinger sol’n

Half in the following in 16 hr

Burn injury mangement



1.Crystalloid but not colloid fluid resuscitation in the

first 24 hr.

2.Colloid fluid can be infused 24 hr after burn injury.

3.Volume of resuscitation can be more thanParkland formula if inhalation injury is suspected.

4. General guideline: keep 30-50ml/hr urine output

after acute stage.

Fluid resuscitation



Head and neck: 9%

Each upper limb:9%

Each lower limb:18%

Ant trunk and abdomen: 18%Back and buttock: 18%

Perineum:1%

Body surface area



Scald burn

Flame burn

Contact burn

Chemical burnElectric burn

Steven Johnson syndrome /Toxic epidermal

necrosis

Burn injury type



• Pediatric or elderly burn or with associated

advanced medical disease (DM) > 10%

• major burn injury >20%

• burn injury involving joints or perineum

Burn center admission



Wound dressing with sulfa silverdiazine (Uburn) cream- leukopenia/reversible

Debridement

Skin graft

Burn wound management



Facial bone fracture

Facial lacerations

Facial trauma



Watch out for lacrimal duct, facial nerve,

or salivary gland injury

Facial laceration



Perioribital numbness (infraorbital nerve)

Diplopia

Malocclusion

TrismusFacial deformity

Watch out for associated head injury

s/s in faical bone injury



X-ray

Water’s view:

Zygoma /arch view:

Nasal bone: most common facial fxCT scan: more sensitive and specific than CT

Image study



Open bone fracture

Tendon /muscle injury

Nerve injury

Vascular injury/amputationCompartment syndrome

Upper & lower extremity injury



Etiology :

Trauma/bone fracture

Crush injury

Burn injuryVascular injury

Tight cast

Drug overdose

Compartment syndrome



Traditional 5 P of acute ischemia are not

reliable.

Pain out of proportion to the injury and

worsens on passive movement shouldarouse suspicion.

Usually tissue pressure > 35 mmHg

s/s of compartment syndrome



Early and prompt fasciotomy prevent further

tissue and nerve injury.

Fasciotomy is urgently done based on clinical

finding not measurement of an absolutevalue in tissue pressure

Tx of compartment syndrome



Etiological risk:

1.Peripheral neuropathy

2 Peripheral vascular disease

Diabetic foot



Ischemic tissue due to pressure on tissue

greater than the arteriole oncotic pressure.

Presure –time relationship

Grade I-IV

Decubitus ulcer



Moisture

Friction:

Shear force: avoid > 30 degree head up in

supine position

Risk factors



Tx

Osteotomy of bony prominence

Debridement

VAC negative pressure wound closure.

Decubitus ulcer



S/S:

5P: pain, paresthesia, pallor, pulselessness,

poikilothermia

hairless & scaly skin, intermittent claudication

Ankle-brachial index (ABI) <1

PAOD (Peripheral arterial occlusion disease)



Image study: CT angiography, angiography

Intervention: angioplasty. Bypass surgery

PAOD



Venous congestion results in hypoxia of

local tissue

Perivascular thick fibrin also impede oxygen

diffusionLeukocyte migrate more slowly than usual

and become activated, damaging the

vascualr endothelium.

Macromolecule/hemosiderin leaking into the

Venous ulcer



Keep wound moist and clean

Compression and debridement

Skin graft or bilayer skin substitute.

Hyperbaric oxygen therapy may helpstasis dermititis healing.

Tx of venous ulcer



Neuropathic impairment of musculoskeletal

balance

Decrease immune system from leukocyte

dysfunction and peripheral vascular diseaseTx :

Keep wound clean and moist, attentive

debridement and use of PDGF and TGF-beta

th f t t i l t i d

Diabetic ulcer

nursing care in plastic surgery

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