OBJECTIVES

General Objectives:

At the end of the case presentation, the students will be able to acquire knowledge,

basic skills and develop desirable attitudes through the utilization of the nursing process in

the care of patient with lacerated wound.

Specific Objectives:

Specifically this case presentation aims to:

 Define lacerated wound.

 Discuss the Anatomy and Physiology of muscular system specifically the

forearm.

 Identify the causes, signs and risk factors in lacerated wound.

 Assess client.

 Identify nursing problems related to lacerated wound.

 Plan and implement appropriate nursing interventions for client.

1
 INTRODUCTION

A wound occurs when the integrity of any tissue is compromised (e.g. skin

breaks, muscle tears, burns, or bone fractures). A wound may be caused by an act, such as a

gunshot, fall, surgical procedure; by an infectious disease; or by an underlying condition; and

in this case, by blast incident.

Lacerations from blunt impacts may show bridging, as connective tissue or

blood vessels are flattened against the underlying hard surface. The term laceration is

commonly misused in reference to incisions.

These wounds are torn, rather than cut. They have ragged, irregular edges and

masses of torn tissue underneath. These wounds are usually made by blunt (as opposed to

sharp) objects. A wound made by a dull knife, for instance, is more likely to be a laceration

than an incision.

Soft tissue injuries of the hand rarely are life threatening. However, the high

incidence of disability from chronically painful or unstable joints is reflected by the fact that

hand derangements account for 9% of all worker compensation claims.

Bomb fragments often cause lacerations. Many of the wounds caused by

accidents with machinery are lacerations; they are often complicated by crushing of tissues as

2
well. Lacerations are frequently contaminated with dirt, grease, or other material that is

ground into the tissue. They are therefore very likely to become infected.

The costs for treating these injuries are considerable and include not only the direct

costs of repair but also the indirect costs borne by the patient, his or her family, and society.

These indirect costs include, for example, time off from work and costs incurred while

seeking care.

Skin wounds of the hand, although commonplace, should not be trivialized. They

must be handled with a methodical and thorough approach to optimize outcome and

minimize morbidity.

Antibiotic prophylaxis is indicated in human (including fight-bites) and cat bites and

may be of benefit in dog bites as well. The use of antibiotics in other hand wounds is

controversial but generally is best reserved for contaminated wounds and puncture wounds

with possible retained foreign bodies.

Hand wounds older than 6-8 hours should not be closed primarily because of an

increased likelihood of infections. Irrigate and explore such wounds and apply a sterile

dressing. Recheck the wound in 2-4 days, with consideration of delayed primary closure at 4

days.

3
Definition of Terms

Actin – a contractile protein of muscle.

Adenosine Triphosphate (ATP) – a compound that is the important intracellular energy

source; cellular energy.

Creatinine Kinase – an enzyme of the transferase class in muscle, brain and other tissues. It

catalyzes the transfer of a phosphate group from adenosine triphosphate to creatinine,

producing adenosine diphosphate and phosphocreatinine.

Creatinine Phosphate – an enzyme that increases in the blood levels when muscle damage

has occurred, as in pseudohypertrophic muscular dystrophy.

Endomysium – the thin connective tissue surrounding each muscle cell.

Epimysium – the sheath of the fibrous connective tissue surrounding a muscle.

Glycolysis – breakdown of glucose to pyruvic acid; anaerobic process.

Lactic acid – the product of anaerobic metabolism, especially in muscle.

4
Muscle – a kind of tissue composed of fibers that are able to contract, causing and allowing

movements of the parts and organs of the body.

Muscular system – all of the muscle of the body, including smooth, cardiac and skeletal or

striated muscle, considered as and interrelated group.

Perimysium – the connective tissue enveloping bundles of muscle fibers.

Pyruvate kinase – is an enzyme involved in glycolysis. It catalyzes the transfer of a

phosphate group from phosphoenolpyruvate (PEP) to ADP, yielding one molecule of

pyruvate

Radius – one of the bones of the forearm lying parallel to the ulna, proximal end is small and

forms a part of the elbow joint, distal end is large and forms a part of the wrist joint.

Sarcomere – the smallest contractile unit of muscle; extends from

Skeletal muscle – are composed of bundle of parallel, striated fibers under voluntary

control.

5
 ANATOMY AND PHYSIOLOGY

Muscles are often viewed as the "machines" of the body. They help move food from

one organ to another, and carry out our physical movement. There are approximately 639

skeletal muscles in the human body. However, the exact number is difficult to define because

different sources group muscles differently.

Muscle (from Latin musculus, diminutive of mus "mouse") is contractile tissue of the

body and is derived from the mesodermal layer of embryonic germ cells.

One of the most amazing things about the human body is the incredible range of

movement and mobility it has. This day to day activity is accomplished by our muscles

through the extraordinary and fascinating ability of converting chemical energy, energy

stored in nutrients, into mechanical energy, energy of movement.

Within the voluntary skeletal muscles, the glucose molecule can be metabolized

anaerobically in a process called glycolysis which produces two ATP and two lactic acid

molecules in the process (note that in aerobic conditions, lactate is not formed; instead

pyruvate is formed and transmitted through the citric acid cycle).

• Biceps brachii – two-headed muscle of anterior arm, proximal to radius, it flexes

elbow and supinates forearm.

6
 • Brachialis – immediately deep to the biceps brachii. Anterior surface of distal

humerus, a major arm flexor.

• Brachioradialis – superficial muscle of lateral forearm distal to humerus, synergist of

brachialis in forearm flexion.

• Pronator teres – anterior forearm; superficial to brachialis, distal humerus and

choronoid process of ulna it pronates forearm.

• Flexor Carpi Radialis – superficial that runs diagonally across forearm, is the medial

epicondyle of humerus, it is the powerful wrist flexor abducts hands.

• Flexor Carpi Ulanaris – superficial medial to flexor carpi medialis. The distal to

humerus and posterior to ulna. Powerful flexor of wrist and adduction.

• Flexor Digiturom Superficialis – deeper muscle that overlain to all muscle of

forearm, it flexes wrist and middle phalanges of second through fifth fingers.

PHYSIOLOGY

The three (skeletal, cardiac and smooth) types of muscle have significant differences.

However, all three use the movement of actin against myosin to create contraction. In

skeletal muscle, contraction is stimulated by electrical impulses transmitted by the nerves, the

motor nerves and motoneurons in particular.

7
 All skeletal muscle and many smooth muscle contractions are facilitated by the

neurotransmitter acetylcholine.

Muscular activity accounts for much of the body's energy consumption. All muscle

cells produce adenosine triphosphate (ATP) molecules which are used to power the

movement of the myosin heads. Muscles conserve energy in the form of creatine phosphate

which is generated from ATP and can regenerate ATP when needed with creatine kinase.

Muscles also keep a storage form of glucose in the form of glycogen. Glycogen can

be rapidly converted to glucose when energy is required for sustained, powerful contractions

Muscle cells also contain globules of fat, which are used for energy during aerobic

exercise. The aerobic energy systems take longer to produce the ATP and reach peak

efficiency, and requires many more biochemical steps, but produces significantly more ATP

than anaerobic glycolysis.

A majority of the muscle in the forearm help control a part of the arm. Among these

is the Berachiodialis major-sound, palmaris longus-sound, and Flexor carpi radialis-sound.

The name of the flexor carpi radialis is a good example of how muscles are named by their

function and location. This muscle is named carpi because of the bones that it helps move,

the carples. Also, the name of radialis is made by the bone that its attached to, the radius.

Biographical Data

8
Name: Mrs. W. N.

Case Number: 161312-2008

Age: 30 years old

Address: Manika, Libacao, Aklan

Birthday: November 22, 1977

Birthplace: Libacao, AklanSex: Female

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Occupation: Housewife

Blood Type: “O”

Admission Date: September 14, 2008

Admission Time: 2:37PM

Admission Diagnosis: 8cm Laceration in Right Arm ; Nerve Injury 2o to Blast Injury

Attending Physician: Dr. R..J.L.

Chief Complaint: Blast Injury

Principal Operation: “E” Debridement, Exploration of Wound; Myorrhapy possible

Neurorrhapy of Radial Nerve.

Operation Performed: Debridement Myorrhapy Right Forearm with Short Arm Posterior

Mold.

9
Vital Signs: BP-145/85 mmHg

PR-100 bpm

SO2- 99%

Hand Dominance: Right Hand

Occupation /Hobbies: Housewife, but occasionally sell goods at her makeshift stall during

market day at their place .

History of previous hand problems: None. Except for minor scratches and lacerations

from ADL’s.

Other past medical history: No history of DM, or other vascular disease.

Lifestyle: Doesn’t smoke, but drinks alcohol occasionally.

History of Current Diagnosis

Prior to admission, at about 9AM , the patient was the attendant of their store.

She placed bottles of beer inside the ice bucket which has been exposed under the sun. At

around 11AM, somebody bought and upon getting the bottle from the bucket, it bursts and its

fragment strikes on her right arm and buried deep into the muscles.

She applied pressure on the lacerated site with her left hand then she

was brought o the health center. Her wound was cleaned and a dressing was applied. The

physician was not there, so she was advised to seek a physician. They went to the doctor near

10
their place. The wound was examined and the dressing was changed. She was referred to the

hospital for further treatment since the doctor has incomplete equipments.

HEAD TO TOE ASSESSMENT

Head and neck: No lesion or parasitic infection. Presence of dandruff

Neurologic System: Pupils are uniform in size & shape. Difficulty moving the middle finger

Extremities and Skin: Presence of lacerated wound of the right forearm, even distribution of

hair in extremities

Respiratory: RR of 16bpm, symmetry in chest wall upon breathing, no wheezing, coughing,

rales and dyspnea noted.

Abdomen and GI: Regular bowel movement, presence of bowel sounds, no discoloration or

tenderness noted.

GU: noted a clear lt. yellow colored urine, LMP Aug. 29, 2008, and has regular menstrual

cycle.

24-HOUR DIETARY RECALL

Breakfast: Rice, Fried Egg and a cup of coffee

Lunch: Rice, Sinigang na Baboy, 1 banana

Dinner: Rice, Fried fish and 2 glass of water

LABORATORY & DIAGNOSTIC TEST

11
Hematology Report: September 16, 2008 (3:21PM)

Result Normal Values Significance

Hemoglobin 125g/L 120-160 Normal

Hematocrit 0.37volFr 0.36-0.41 Normal

RBC 4.08x1012/L 4.20-5.40 Indicates possible anemia /

hemorrhage

WBC 9.3x109/L 4.50-11 Normal

Platelet Adequate 150-460 Normal

Segmenters 0.63 0.36-0.66 Normal

Lymphocytes 0.37 0.24-0.44 Normal

NURSING CARE PLAN

12
 Pre-Operative

Assessment

Subjective:

“Nakoebaan ako operahan” as verbalized by patient.

Objective:

 Restlessness

 Voice quavering

 Poor eye contact

 Anxious (moderate) whereas 1- mild, 5- moderate, 10- severe.

Nursing Diagnosis:

Anxiety related to surgery.

Planning

General Objectives:

To promote comfort and facilitate expression of anxiety.

Specific Objectives:

After rendering nursing interventions, the patient will be able to:

13
  Communicate needs and negative feelings appropriately.

 Verbalize reduction in the level of anxiety experienced from moderate to

mild.

Nursing Interventions:

 Introduce self, address the patient by name warmly, provide explanations and

encourage and answer questions.

Rationale: Provide sense of friendliness that can help the patient feel secure.

 Use common basic communication skills such as touch and eye contact.

Rationale: Reduces anxiety.

 Stay with the patient.

Rationale: The presence of a trusted person assures patient of her security and

safety during a period of anxiety.

 Orient patient to the environment.

Rationale: Provides comfort and decreases anxiety.

 Tell the patient who else will be present in the OR, how long the procedure is

expected to take.

Rationale: Helps the patient prepare for the experience.

Implementation:

14
 1) Introduced self, addressed the patient by name warmly, provided explanations and

encourage and answer questions.

2) Used common basic communication skills such as touch and eye contact.

3) Stayed with the patient.

4) Oriented patient to the environment.

5) Told the patient who else were present in the OR, and the estimated time the

procedure is expected to take.

Evaluation:

Goals met.

The patient:

 Expressed needs and negative feeling.

 Verbalized reduction of anxiety

Intra-Operative

15
Assessment

Objective Data:

 Disruption of skin surface

 Disruption of skin layers

Nursing Diagnosis

Impaired skin integrity related to lacerated wound secondary of blast injury.

Planning

General Objective:

To restore skin integrity and promotes timely healing to lesion.

Specific Objectives:

After identifying the problem the patient are expected to:

 Undergone surgery specifically wound repair/suturing

Nursing Intervention
16
 Independent:

 Apply wound dressing aseptically.

Rationale: To optimize the barrier from infection

Dependent:

 Perform wound suturing

Rationale: To restore the integrity of open wound and prevent entrance of

microorganism

 Use proper size of suture needle

Rationale: To prevent further tissue damage.

 Administer antibiotic as ordered.

Rationale: To decrease incidence of wound infection and lessen its severity.

Implementation:

1) Apply wound dressing aseptically.

2) Perform wound suturing

3) Use proper size of suture needle

4) Administer antibiotic as ordered.

17
Evaluation:

Goals partially met.

 Meticulous wound repair was done

 Further trauma was prevented caused by sharp instruments.

 Aseptic technique was strictly observe.

 Proper wound dressing was performed.

 Signs & Symptoms of infection was not noted because it arises after 72 hours.

Assessment
18
 Objective Data:

 Open wound

Nursing Diagnosis:

Risk for infection related to open wound.

Planning

General Objective:

To prevent from infection.

Specific Objectives:

Throughout the operation the patient will:

 Keep from introduction of infection

Nursing Intervention

Independent:

 Perform hand scrubbing, gowning and gloving before participating in

operation.

Rationale: To prevent introduction of microorganism to the patient.

 Observe 12 principles of sterile technique.

19
 Rationale: To ensure control of infection.

Dependent:

 Perform wound suturing.

Rationale: To restore the integrity of open wound and prevent entrance

of microorganism

 Use proper size of suture needle

Rationale: To prevent further tissue damage

 Administer antibiotic as ordered.

Rationale: To decrease incidence of wound infection and lessen its

severity.

Implementation:

1) Perform hand scrubbing, gowning and gloving before participating in

operation.

2) Observe the 12 principles of sterile technique.

3) Apply wound dressing aseptically.

4) Perform wound suturing.

5) Use proper size of suture needle.

6) Administer antibiotic as ordered.

20
Evaluation

Goals partially met. The proper aseptic technique and control of infection was

observed. But then, the infection was not noted because signs and symptoms of infection

arises after 72 hours.

Drug Study

21
Generic Name:

Ampicillin

Trade Name:

Ampicin

Classification:

Antibiotics; Penicillin

Route and Dosage:

1 gm every 8 hours IVTT ANST (-)

Action:

Bactericidal action against sensitive organisms; Inhibits synthesis of bacterial cell

wall, causing cell death.

Indication:

Treatment of infections

Contraindication:

Contraindicated with allergies to penicillin; cephalosporin or other allergens

22
Adverse Effect:

CNS: Lethargy, hallucinations, seizures

CV: CHF

GI: Glossitis, stomatitis, gastritis, sore mouth, furry tongue, black “hairy” tongue,

nausea, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis

pseudomembrane colitis, nonspecific hepatitis

Nursing Responsibilities:

1. Observe 3 checks and 10 rights in drug administration.

 To prevent committing mistakes in giving or administering drugs.

2. Administer medication slowly 2-3 minutes.

 To prevent discomfort to patient

3. Advise client to increase fluid intake.

 To prevent dehydration when diarrhea and vomiting occur.

23
Generic Name:

Ranitidine

Trade Name:

Zantac

Classification:

Histamine2 (H2) Antagonist

Route and Dosage:

50mg, IVTT

Action:

Competitively inhibits the action of histamine at H2 receptors of the parietal cells of

the stomach, inhibiting basal gastric acid secretion that is stimulated by food, insulin,

histamine, cholinergic agonist, gastrin, and pentagastrin.

Indication:

To prevent aspiration.

24
Contraindication:

Contraindicated to patient with impaired renal or hepatic functions

Adverse Effect:

CNS: headache, dizziness, malaise, somnolence, insomnia, vertigo

CV: tachycardia, bradycardia, PVC’s (rapid IV administration)

Dermatologic: rash, alopecia

GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis

GU: Gynecomastia, impotence or decreased libido

Local: local burning at itching at IV site

Nursing Responsibilities:

 Observe 10 rights on drug administration.

Rationale: To secure safety of the patient during drug administration.

 Observe IV site for redness and/or swelling.

Rationale: Redness and swelling may not be a potential side effect of

IV drug. Action should be done immediately to prevent further

complication.

 Increase fluid intake.

Rationale: To prevent constipation & replace GI looses.

25
  Raise the side rails of the patient’s bed.

Rationale: To provide safety during episodes of headache, dizziness &

malaise.

Generic Name:

26
 Cephalexin

Trade Name:

Biocef

Classification:

Antibiotic; Cephalosporin

Route & Dosage:

500 mg/cap every 6 hours, PO

Action:

Inhibits synthesis of bacterial cell wall, causing cell death

Indications:

Skin and skin structure infections caused by staphylococcus/streptococcus

Contraindications:

Allergy to cephalosporins or penicillins

Adverse Effect:

27
 CNS: headache, dizziness, lethargy, paresthesias,

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity

GU: Nephrotoxicity

Hematologic: Bone marrow depression

Nursing Responsibilities:

 Administer drugs with meals.

Rationale: To avoid GI upset

 Advise client to increase fluid intake if nausea and diarrhea occur.

Rationale: As potential side effects GI loses and electrolytes are lost

and need to be replaced.

 Ensure patients compliance to medication.

Rationale: To ensure effectiveness of medication and to prevent drug

resistance.

Generic Name:
28
 Ketorolac Tromethamine

Trade Name:

Toradol

Classification:

Non-Opioid Analgesics; Non-Steriodal Anti-inflammatory Drug

Route & Dosage:

30mg/amp 1 ampule every 8 hours, IVTT

Action:

Anti-inflammatory and analgesics activity; Inhibits prostaglandins and leukotriene

synthesis.

Indication:

Short management for pain.

Contraindication:

Contraindicated with significant renal impairment; Aspirin allergy.

Adverse Effect:

29
 CNS: Headache, dizziness, somnolence, insomnia, fatigue, tinnitus, ophthalmologic

effect

Dermatologic: Rash, pruritus, sweating, dry mucous membrane.

GI: Nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, gastric or duodenal

ulcers.

GU: Dysuria, renal impairment

Respiratory: Dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis

Others: Peripheral edema and local burning

Nursing Responsibilities with Rationale:

 Administer medication slowly 2-3 minutes

Rationale: To prevent irritation in the IV site and discomfort to patient.

 Instruct client to increase fluid intake.

Rationale: To promote drug excretion

 Advise client to ask for assistance when getting out of bed.

Rationale: To prevent from injury

Generic Name:
30
 Promethazine

Trade Name:

Phenergan

Classification:

Antivertigo Drugs / Antihistamines & Antiallergics

Action:

A phenothiazine derivative, blocks postsynaptic dopaminergic receptors in the brain

and has a strong α-adrenergic blocking effect. It competitively binds to H1-receptors.

Route & Dosage:

25 mg IM

Indication:

Treatment and prevention of motion sickness; prevention and control of nausea and

vomiting associated with anesthesia and surgery.

Contraindication:

Should not be administered to patients who are hypersensitive to this drug.

Side/Adverse Effect:

31
 CNS: drowsiness, blurred vision, dizziness, tinnitus, tremors

CDV: increase BP, tachycardia, faintness

Dermatologic: dermatitis, photosensitivity, urticaria

Hema: leucopenia, thrombocytopenia

GI: Nausea & vomiting, dry mouth

Resp.: asthma, respiratory depression, apnea

Nursing Responsibilities w/ Rationale:

 Administer drugs utilizing 10 rights of drug administration.

Rationale: To provide client safety.

 Take drug exactly as prescribed.

Rationale: To prevent drug resistance

 Avoid using alcohol during therapy.

Rationale: CNS depression may occur

 Avoid prolonged exposure to sunlight.

Rationale: To avoid photosensitivity

 Increase fluid intake.

Rationale: To promote drug excretion.

Generic Name:
32
 Nalbuphine HCl

Trade Name:

Nubain

Classification:

Analgesic (Non-Opioid) & Antipyretics

Action:

It inhibits the ascending pain pathways, altering the perception of & response to pain

by binding to opiate receptors in the CNS. It also produced generalized CNS depression.

Route & Dosage:

5mg IVTT

Indication:

It is indicated for the relief of moderate to severe pain & it can also be used as a

supplement to balanced anesthesia, for preoperative and postoperative analgesia.

Side/Adverse Effect:

33
 CNS: Nervousness, depression, restlessness, faintness, hallucinations, dysphoria,

numbness

CDV: Hypertension, hypotension, bradycardia, tachycardia

GI: Nausea & vomiting, Cramps, dyspepsia, dry mouth

Resp: Depression, dyspnea, asthma

Dermatologic: Itching, burning, urticaria

Contraindication:

Should not be administered to patients who are hypersensitive to nalbuphine

hydrochloride, or to any of the other ingredients in NUBAIN.

Nursing Responsibilities w/ Rationale:

 Administer drugs utilizing 10 rights of drug administration.

Rationale: To provide client safety.

 Use exactly as directed.

Rationale: Drug may cause physical or psychological dependence.

 Maintain adequate hydration.

Rationale: To promote drug excretion.

 Instruct patient to move slowly.

Rationale: To prevent orthostatic hypotension

Generic Name:
34
 Tetanus Toxoid

Classification:

Anti-tetanus

Action:

Tetanus toxoid preparations contain the toxin produced by virulent bacilli (detoxified

growth products of Clostridium Tetani), this toxin modified for treatment with formaldehyde

so that it has lost toxicity but still retains ability to act as antigen & produced active

immunity.

Route & Dosage:

0.5 cc IM

Indication:

Prevention & treatment of tetanus.

Side/Adverse Effect:

chills, fever, seizures, sterile abscess at injection site, lymphadenopathy, &

anaphylactic reaction

35
Contraindication:

Severe infection. Febrile illness.

Nursing Responsibilities w/ Rationale:

 Observe 10 rights of drug administration.

Rationale: To provide client safety.

 Inform client that the nodule may be palpable at the injection site for few weeks.

Rationale: To aware the patient & prevent anxiety.

 Tell the patient that it cause mild fever, soreness, swelling & redness where the

injection site.

Rationale: To inform the patient the possible side effect of medication to the

injection site.

EVALUATION
36
Presentation of Program – refers to the facilities to be used in the presentation. It is

categorize into 5: the organization, appropriateness of physical facilities, the relevant of

objectives to theme/topic, evidence of management and leadership skills and materials used.

Very Good - 27 – 40

Good - 14 – 26

Poor - 0–3

Content and Proceedings – it refers to the contents of the case on how the presenters

understand the case presented and how they organized the presentation. It is categorized into

5: knowledge and mastery of content, organization, clarity/speaking ability, effectiveness of

teaching method and objectives met.

Very Good - 21 – 30

Good - 11 – 20

Poor - 0 – 10

Presentation of Paper – it refers to the materials used in the presentation if it is organized,

complete and with proper documentation.

Very Good - 21 – 30

Good - 11 – 20

Poor - 0 – 10

INTERPRETATION

37
 TABLE I
Distribution of participants according to their evaluation to our case.

f
N = 44 % Total
I. Presentation of the Program (40%)
Very Good 41 93.18 93.18
Good 3 6.82 6.82
Poor 0 0 0
Total 44 100
II. Content and Proceedings (30%)
Very Good 40 90.19 90.19
Good 4 9.09 9.09
Poor 0 0 0
Total 44 100
III. Presentation of Paper (30%)
Very Good 39 88.64 88.64
Good 5 11.36 11.36
Poor 0 0 0
Total 44 100

The data shows that in the first category majority of the participants (93.18%) have
rated us with very good presentation of program and only (6.82%) of them said that we had
performed well. On the second, 90.19% had evaluated us with very good performance and
only 9% of them rated us with good performance. On the third category (88.64%) had
evaluated us with very good and (11.36%) respectively rated us good performance.

38