Pressure Sores

Also called as decubitus ulcers. It is a localized ulceration of the skin and deeper structures. Most commonly results from prolonged periods of bed rest. Friction (causing abrasion of the stratum corneum) and shearing (sliding of adjacent surfaces causing rupture of capillaries) forces contribute to the destructive mechanism of pressure. Risk factors for pressure sores include bowel or bladder incontinences, malnutrition or significant weight loss, edema, anemia, hypoxia, hypotension, neurological impairment, immobility, and altered mental status. Complication includes tissue loss, infection, and sepsis.

Assessment 1. Presence of risk factors. 2. Frequent observation of the skin, especially over pressure points.

3. Staging of the pressure sore to initiate appropriate treatment:

Stage I nonblanching macule that may appear red or violet. Stage II skin breakdown as far as the dermis. Stage III skin breakdown into the subcutaneous tissue. Stage IV penetrates bone, muscle, or joint. Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined 4. For stage IV pressure sores, assess for depths of ulcer and presence of tunneling; measure the entire diameter and depth of the ulcer. Diagnostic Evaluation 1. No testing is usually indicated. 2. Wound cultures are usually inaccurate due to bacterial contamination and colonization, but may be done to guide antibiotic therapy when signs of infection are present. Therapeutic Interventions 1. Pressure must be relieved and maceration, friction and shearing forces avoided for wound healing to take place. 2. Normal saline is used for routine cleansing once to several times daily depending on the amount of wound drainage, unless a protective dressing is used. 3. Wet to dry dressings may be used to assist with mechanical debridement. 4. Debridement of devitalized tissue may be necessary using scissors and scalpel following sterile technique. 5. Protective wound dressings may be used to minimize disruption of migrating fibroblasts and epithelial cells and to provide moist, nutrient rich environment for healing.

Pharmacologic Interventions 1. Debriding enzymes may be used for stage III to IV ulcers; may damage healthy tissue and are not appropriate for hard eschar. 2. Topical antibiotics may be used to treat signs of local wound infection. 3. Analgesics are usually needed, particularly 30 to 60 minutes before wound care. Nursing Interventions 1. Monitor for signs of local infection (erythema around edges, foul odor, purulent exudates, poor healing) as well as sepsis (fever, cellulites around wound, increased pain, decreased blood pressure, tachycardia, altered level of consciousness). 2. Assess size of pressure sore weekly in response to therapeutic measures; document the largest diameter, not just the surface diameter, and document the greatest depth. 3. Monitor pain level and response to pain medication; in unresponsive patient, look for agitation, tachycardia and increased blood pressure to indicate pain. 4. Use pressure0 reducing surface to help prevent pressure sores, but they are not effective in treating established pressure sores. 5. Avoid elevating head of the bed more than 30 degrees to prevent shearing force as the patient slides downward against mattress. 6. Encourage activity and ambulation as much as possible. 7. Turn and reposition patient every 2 hours. 8. Bathe patient as needed with a bland soap, rinse, and blot dry with a soft towel. 9. Lubricate skin at least twice daily with a bland cream or gel, especially over pressure points. 10.Employ bowel and bladder program to prevent incontinence. 11.Avoid plastic coverings and poorly ventilated chair or mattress surfaces. 12.Ensure that high protein, nutritious diet is provided, utilize supplements as necessary and ensure adequate fluids to hydrate skin. 13.Clean pressure sore, as directed or per protocol; use normal saline or prescribed solution, irrigate as necessary to remove exudates, but do not disrupt healing tissue. 14.Teach diet rich in protein, iron, and vitamin C to aid in full healing.

Fractures
is a break in the continuity of bone. A fracture occurs when the stress placed on a bone is greater than the bone can absorb. The stress may be mechanical (trauma) or related to a disease process (pathologic). Muscles, blood vessels, nerves, tendons, joints, and body organs may be injured when fracture occurs.

1.

A fracture is a break in the continuity of the bone. 2. Common fracture sites: Clavicle Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site. Radius and ulna Femur (often associated with child abuse) Epiphyseal plates (potential for growth deformity) 3. Types of Fracture Closed or simple fracture The bone is broken, but the skin is not lacerated. Open or compound fracture- The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture The fracture is at right angles to the long axis of the bone. Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone. Comminuted fracture - A fracture that results in three or more bone fragments. Oblique Fracture The fracture is diagonal to a bones long axis.

Spiral Fracture At least one part of the bone has been twisted. 4. Complications of fractures include: problems associated with immobility (muscle atrophy, joint contracture,pressure sores) growth problems ( in children) infection shock venous stasis and thromboembolism pulmonary emboli and fat emboli and bone union problems

B. Etiology 1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. 2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. C. Pathopysiology 1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. 2. Fractures most commonly seen in children: Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention. Buckle fracture results from compression failure of the bone, with the bone telescoping on itself. Greenstick fracture is an incomplete fracture. D. Assessment Findings 1. Clinical Manifestations The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children). 2. Laboratory and diagnostic findings Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity.

Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

E. Nursing Management 1. Provide emergency management when situation warrants, for a new fracture. Assess the five Ps. Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps. Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services. 2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications. 5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage.

Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. Treatment entails pressure relief, which sometimes require performing a fasciotomy.

8. Prevent infection, including osteomyelitits, bys using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.