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May 2008 Nursing Treatment Profiles m ay 2 0 0 8 Nursing Treatment Profile ACC4593 • ISBN: 978–0–478–31425–0 • printed May 2008 May 2008 EDITION Prepared by ACC P O Box 242, Wellington, New Zealand www.acc.co.nz ACC Provider Helpline: 0800 222 070 ACC Enquiry Service Centre: 0800 101 996 Introduction The Nursing Treatment Profiles are intended as a resource for nurses to help summarise current practice in the management of injuries. They are consensus based (not evidence based) and are not rigid protocols. ACC is responsible for providing access to the most effective treatment, rehabilitation and support services to help patients lead as normal a life as possible after injury. These Nursing Treatment Profiles are available to assist nurses working with ACC to achieve this goal. What is a Treatment Profile? A treatment profile is a guide to the treatment and rehabilitation services ACC expects patients to receive for a particular injury. The profiles cover a wide range of common injuries and are intended to provide flexibility and choice in clinical judgement according to the patient’s individual circumstances. A comprehensive nursing assessment should be the starting point of any engagement with the patient. The depth of detail required should be appropriate to the severity of the injury and level of intervention required. A guide to a comprehensive nursing assessment, with an example of the assessment tool in use at MidCentral District Health Board, is included at the back of this document. Return to work is an important aspect of a patient’s injury. A patient who may not be able to return immediately to full duties may return on modified duties. This is an important consideration after a patient has sustained a personal injury. It is beneficial for a patient to return to work even if they are is on modified duties. All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Incapacity for work includes modified and alternative duties, and reduced hours. It is always important to consider which tasks can be done safely, within the limitations of the injury, and whether there are alternative duties available. It is important to communicate with the patient as well as their employer and members of the multidisciplinary team to ensure there is a complete and inclusive approach to the rehabilitation. Counselling is also a valuable aspect of rehabilitation to ensure any pertinent psychosocial needs are met which will assist in the recovery. Counselling is, however, a very personal experience, and some people are extremely reluctant to consider this. It may be appropriate to suggest counselling, with a simple explanation of what the patient may expect and a list of available counselling services. It is then up to the patient to decide whether they wish to seek counselling. Social rehabilitation assessments are undertaken by contracted providers to assess patients’ needs for a range of specific social and nursing services, including activities of daily living. It may be appropriate to refer the patient for such an assessment if it is indicated following the initial comprehensive nursing assessment. The treatment profiles were written by an experienced and expert group of nurses and peer reviewed. The treatment profiles are organised into categories according to injury. An overview is included at the beginning of some sections to provide additional information relevant to that particular injury type. Generally, the following headings under each injury include: • Key Points • Classifications • Complications i • • • • • • • • History Assessment Differential Diagnosis Investigation Action Plan Follow-up Treatment Onward Referral Patient Education References are available on request. A glossary is included at the end of this publication. Available ACC and other resources are listed at the end of each section. These resources are continuously revised and updated. The up-to-date versions are available via the ACC website at www.acc.co.nz. ii Contents Section One: Fractures and Dislocations............................................................................................................5 Overview...........................................................................................................................................................7 Key Points for Management............................................................................................................................ 7 Ankle Fracture Types....................................................................................................................................... 8 Codes and injuries S120. Closed Rib Fracture................................................................................................................ 9 S20.. Closed and Non-Displaced Clavicle Fracture.........................................................................12 S22.. Closed Fracture Humerus, Proximal Shaft.............................................................................14 S2241 Closed Fracture Distal Humerus, Supracondylar....................................................................16 S230./S231. Fracture Proximal Radius and Ulna.......................................................................................19 S232./S233. Fracture Shaft Radius and Ulna............................................................................................22 S234./S235. Fracture Distal Radius and Ulna............................................................................................25 S2401 Closed Fracture Scaphoid.....................................................................................................28 S24Z. Fracture Carpal Bone............................................................................................................31 S25.. Fracture Metacarpal Bone.....................................................................................................34 S26.. Fracture Phalanges Hand......................................................................................................37 S33.. Fracture Tibia and Fibula......................................................................................................40 S34.. Fracture Ankle......................................................................................................................44 S352. Closed Fracture Other Tarsal/Metatarsal...............................................................................47 S36.. Closed Fracture Phalanges Foot............................................................................................49 S41.. Dislocation/Subluxation Shoulder.......................................................................................51 S44.. Dislocation/Subluxation Finger/Thumb................................................................................54 Section Two: Burns..........................................................................................................................................57 Overview.........................................................................................................................................................59 Key Points for Management..........................................................................................................................59 Burn Depth Assessment...............................................................................................................................60 Codes and injuries SHO.. Burn Eye and Adnexa...........................................................................................................65 SH1.. Burn Face, Head, Neck.........................................................................................................67 SH2../SH3../SH5.. Burn Trunk/Arm (Excluding Wrist, Hand)/Lower Limbs..........................................................69 SH4.. Burn Wrist and Hand............................................................................................................71 Section Three: Gradual Onset..........................................................................................................................73 Codes and injuries F340. Carpal Tunnel Syndrome.......................................................................................................74 N211. Rotator Cuff Syndrome.........................................................................................................76 N2131/N2132 Medial and Lateral Epicondylitis – Elbow.............................................................................78 N2165 Prepatellar Bursitis...............................................................................................................81 N2174/S5504 Achilles Tendonitis/Sprain Achilles Tendon..........................................................................82 N220. Synovitis/Tenosynovitis.......................................................................................................84 1 Section Four: Sprains/Strains..........................................................................................................................87 Overview.........................................................................................................................................................89 Red and Yellow Flags....................................................................................................................................89 Medical Certification for Reduced Work Capacity/Time off Work....................................................................89 Muscle Strains.............................................................................................................................................90 Ligament Sprains.........................................................................................................................................90 X-Ray Rules..................................................................................................................................................90 Soft Tissue Injury..........................................................................................................................................91 Chronic Neck Pain........................................................................................................................................92 Codes and injuries N142./S572./N143. Low Back Pain, Acute Back Pain – Lumbar, Lumbago/Lumbar Sprain/Sciatica......................95 N131./S570. Neck Pain/Neck Sprain.......................................................................................................100 S5y3. Sprain Rib..........................................................................................................................103 S500. Sprain Acromio-Clavicular Ligament...................................................................................106 S507./S504./S503./S502. Shoulder/Rotator Cuff Sprains and Tendon Tears (Includes Infraspinatus)...........................108 S51.. Sprain Elbow/Forearm........................................................................................................110 S5Q2./S5Q4. Rupture Supraspinatus/Biceps Tendon...............................................................................112 S52../S524. Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains) Sprain Tendon Wrist or Hand..............................................................................................114 N2264 Hand/Wrist Flexor Tendon Rupture.....................................................................................116 S5204 Spain Radial Collateral Ligament (Thumb)..........................................................................118 S522. Sprain Thumb....................................................................................................................120 S523./S5513 Sprain Finger......................................................................................................................122 S53../S535. Sprain Hip/Thigh, Sprain Hamstring...................................................................................124 S533. Sprain/Strain Quadriceps Tendon......................................................................................126 S460./S461. Meniscal Tear (Medial/Lateral)...........................................................................................128 S5400/S541. Sprain Collateral Ligament Knee.........................................................................................130 S542. Sprain Cruciate Ligament Knee...........................................................................................132 S550. Sprain Ankle (Lateral Ligaments)........................................................................................134 S5512/S5513 Sprain Metatarso-Phalangeal Joints/Interphalangeal Joint..................................................136 Section Five: Other Soft Tissue Injuries..........................................................................................................139 Overview.......................................................................................................................................................141 Wound management..................................................................................................................................141 Anaesthesia and Analgesia........................................................................................................................142 Antibiotic Prophylaxis and Tetanus Prophylaxis..........................................................................................144 Wound Closure...........................................................................................................................................145 Patient Education.......................................................................................................................................147 Skin Tears..................................................................................................................................................148 Codes and injuries SD000 Abrasion Face....................................................................................................................150 SD20./SD30./SD602/SD60. Abrasion Shoulder/Upper Arm/Lower Arm/Knee/Leg.........................................................151 SD10. Abrasion Trunk...................................................................................................................152 7G321/S935. Abrasion Nail/Open Wound Fingernail................................................................................153 S8… Open Wound Trunk.............................................................................................................154 S82.. Open Wound Ear................................................................................................................155 S830./S8342 Open Wound Scalp/Open Wound Forehead........................................................................156 2 S832./S8341/S8343/S8344/S8345/S836. Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth..........................................................158 S922./S93.. Open Wound Elbow/Forearm/Wrist/Hand, Finger/Thumb...................................................159 S87../S88.. Open Wound Buttock/Ext Genitalia....................................................................................161 S9.../S90../SA10./SA2../SA3.. Open Wound Upper Limb/Shoulder/Knee, Leg/Ankle, Foot/Toe.........................................162 SE0../SE2../SE3../SE4.. Contusion (Bruise) Face, Scalp, Neck/Trunk/Upper Limb/Lower Limb.................................163 Sk0Y. Compartment Syndrome (Acute).........................................................................................165 SF203 Crush Injury Upper Arm......................................................................................................166 SF22. Crush Injury Wrist or Hand..................................................................................................169 SF23./SF231 Crush Injury Finger(s)/Thumb (Open and Closed)...............................................................172 SF322 Closed Crush Injury Foot.....................................................................................................175 Section Six: Miscellaneous............................................................................................................................177 Overview.......................................................................................................................................................179 Anaphylaxis Treatment Protocol..................................................................................................................179 Body Fluid Exposure...................................................................................................................................182 Infection Control........................................................................................................................................184 Head Injury Risk Group...............................................................................................................................186 Glasgow Coma Scale..................................................................................................................................187 Codes and injuries S60.. Concussion........................................................................................................................188 E2A2. Post Concussion Syndrome................................................................................................195 F542. Tympanic Membrane Perforation........................................................................................197 JO510/S8363 Loss of Teeth (Accidental)/Broken Teeth.............................................................................199 M2y5. Foreign Body in Skin or Subcutaneous Tissue.....................................................................200 SD810/SG00. Corneal Abrasions/Corneal Foreign Body............................................................................205 SG1../SG2.. Foreign Body in Ear/Foreign Body in Nose..........................................................................209 SG5.. Ingested Foreign Body........................................................................................................212 TE532 Toxic Reactions Bee Stings.................................................................................................215 SL… Toxic Ingestions (Activated Charcoal).................................................................................218 Spider Bites.......................................................................................................................220 TE60./U120. Dog Bites/Human Bites/Cat Bites......................................................................................222 TL01. Electrical Injury..................................................................................................................227 SN571 Management of Sexual Assault/Abuse in General Practice.................................................231 Glossary/Abbreviations.................................................................................................................................233 Appendix 1: Pain Identification and Management of Pain...............................................................................237 Appendix 2: Example of Electronic Comprehensive Nursing Assessment Form, Courtesy of MidCentral District Health Board.............................................................................................241 Appendix 3: Resources..................................................................................................................................261 3 4 Section One: Fractures and Dislocations Overview...........................................................................................................................................................7 Key Points for Management............................................................................................................................ 7 Ankle Fracture Types....................................................................................................................................... 8 Codes and injuries S120. Closed Rib Fracture................................................................................................................ 9 S20.. Closed and Non-Displaced Clavicle Fracture.........................................................................12 S22.. Closed Fracture Humerus, Proximal Shaft.............................................................................14 S2241 Closed Fracture Distal Humerus, Supracondylar....................................................................16 S230./S231. Fracture Proximal Radius and Ulna.......................................................................................19 S232./S233. Fracture Shaft Radius and Ulna............................................................................................22 S234./S235. Fracture Distal Radius and Ulna............................................................................................25 S2401 Closed Fracture Scaphoid.....................................................................................................28 S24Z. Fracture Carpal Bone............................................................................................................31 S25.. Fracture Metacarpal Bone.....................................................................................................34 S26.. Fracture Phalanges Hand......................................................................................................37 S33.. Fracture Tibia and Fibula......................................................................................................40 S34.. Fracture Ankle......................................................................................................................44 S352. Closed Fracture Other Tarsal/Metatarsal...............................................................................47 S36.. Closed Fracture Phalanges Foot............................................................................................49 S41.. Dislocation/Subluxation Shoulder.......................................................................................51 S44.. Dislocation/Subluxation Finger/Thumb................................................................................54 5 6 Fractures and Dislocations Overview Key Points for Management General • Rest – reduces further damage. Stop activity as soon as the injury occurs. Avoid as much movement as possible to limit further injury. Do not put any pressure or weight on the injured part • Elevation – helps to stop the bleeding and reduce swelling. Raise the injured area on a pillow for comfort and support. Keep the injured area raised for as much of the day as possible. Where possible keep the injured part higher than the heart • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • A patient may report a decrease in function or inability to manage activities of daily living. Encourage the patient to report this to the nurse or medical practitioner Avoid HARMS (Within the First 72 Hours) • Heat – increases the bleeding and swelling at the site. Avoid hot baths or showers, saunas, hot water bottles, heat packs and liniments • Alcohol – can mask the pain of the injury, which may delay seeking appropriate treatment. Alcohol increases bleeding and swelling at the injury site and delays healing • Running – or any form of exercise may cause further damage. Do not resume exercise within 72 hours of the injury unless on the advice of a medical practitioner • Massage – can cause an increase in bleeding and swelling. If the area is massaged within the first 72 hours, it may take longer to heal • Smoking – heavy smoking may reduce the ability for some fractures to heal Neurovascular Monitoring • Teach patients to understand the concepts of neurovascular monitoring and what to do if symptoms occur • If the patient is young or dependent or has English as a 2nd language, ensure a support person has full understanding of the monitoring required • Symptoms: – Severe pain not relieved by simple analgesia or elevation of the affected limb – Severe pain disproportionate to the injury – Changes in colour, either pallor or darkening – Changes in sensation – Untoward swelling – advise patient what to expect and when to return – Difficulty moving unsplinted joint Infection • Teach patients to understand the concepts of infection monitoring and what to do if symptoms occur • If the patient is young or dependent or has English as a 2nd language, ensure a support person has full understanding of the monitoring required 7 • Signs or symptoms of infection: – Local heat, increasing tenderness, inflammation (redness), offensive odour/discharge, swelling – Systemic illness including fever or a flu-like illness, shivering, vomiting – Swelling in joints Pain Medication • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Ensure the patient is aware of the expected effects, known side effects and where to seek further advice for all or any medications they are prescribed Exercise and Rest Advice • • • • Advise limitations of exercise and educate on the reasons for restricting exercise and the timeframes Explain how to remain active and maintain mobility of unaffected joints Encourage gait and muscle strengthening exercises Advise and explain about rest Crutches • Check that patient has been shown/knows correct way to use crutches • Provide education material/information sheet for patient/family • Ensure patient is aware of when to return for advice/treatment Use of a Sling • Refer to: Practical Techniques in Injury Management: Casts and Splints: ACC2373 Ankle Fracture Types Weber Type A: Transverse fibular avulsion (below horizontal ankle joint line). These result from internal rotation and adduction injuries. Usually stable. Weber Type B: Oblique fracture lateral malleolus, with or without rupture of the tibiofibular syndesmosis and medial ligament injury (either medial malleolar fracture or deltoid ligament rupture). These result from external rotational injuries and are either unstable or potentially unstable. Weber Type C: High fibular fracture with rupture of the tibiofibular and transverse avulsion fracture of the medial malleolus. Result from adduction or abduction with external rotation. Usually unstable. 8 Closed Rib Fracture Identifier Read Code Key Points Closed Rib Fracture S120. Most rib trauma is mild and can be treated conservatively, except in the elderly, those with pre-existing respiratory illness and children • Children’s chest walls are very pliable so a rib fracture in a child can indicate underlying injury to heart, lungs and great vessels • Rib fractures in the elderly or those with pre-existing pulmonary disease may warrant admission to hospital due to increased risk of complications • 1st/2nd rib fractures: mortality up to 30% due to aorta and subclavian artery damage, brachial plexus injury • Fractured ribs can damage other surrounding tissues and cause haemothorax and/or pneumothorax, liver, spleen or abdominal viscous injury Flail chest Where 2 or more adjacent ribs are fractured at 2 or more places, this can lead to a free-floating, unstable segment that moves in opposition to the normal chest wall function. On examination, the segment moves in on inspiration and out on expiration. It is often associated with an underlying pulmonary injury. Tension pneumothorax Requires urgent management for needle thoracentesis. Signs and symptoms of tension pneumothorax: • Increasingly severe respiratory distress • Severe pain on inspiration • Absence of decreased air entry on auscultation on side of injury • Distended neck veins • Tracheal deviation to unaffected side of injury • Tachycardia and hypotension • Feeling of impending doom Complications • Pneumonia • Atelectasis • Respiratory distress • Pneumothorax • Haemothorax • Cardiac contusion • Pulmonary contusion • Splenic liver or abdominal injury History • Comprehensive nursing assessment • Mechanism of injury: direct blunt blow to the chest, fall, collision, crush injury • MVAs with activation of airbags and/or a deformed steering wheel • Pain on inspiration • Tachypnoea • Haemoptysis • Respiratory distress • Subcutaneous emphysema continued … 9 Identifier Read Code Assessment (According to Competency) Closed Rib Fracture continued S120. continued Airway with cervical spine injury Note any abnormal airway sounds, especially stridor Breathing • Rate and depth • Symmetry of chest wall movement • Equal breath sounds on auscultation • Accessory muscle use • Observe for cyanosis, change in colour • Trachea central • Note any bruising, contusion, grazing Circulation • Heart rate and rhythm • BP • Skin colour and warmth (patient may be pale and sweaty) • Observe for signs of shock Secondary survey • Observe for any abnormalities of the chest wall • Palpate abdomen for pain, rigidity, guarding – risk of spleen or liver injury • Listen for presence of bowel sounds • Complete full secondary survey to ensure no other injuries Differential Diagnosis • Sternal fracture • Sternoclavicular joint injury • Scapular fracture • Acute respiratory distress syndrome • Aortic dissection • Pneumothorax • Pneumonia/Respiratory tract infection • Pulmonary embolus • Spinal injury • Abdominal trauma, blunt or penetrating • Abdominal viscus injury • Cardiac injury Investigation X-ray • X-rays (only 50% detection on first X-ray): – Chest PA and lateral – Oblique view of the side involved – Coned upper abdominal AP view if lower ribs involved – Others to consider: inspiratory views, plain abdomen (erect, lateral decubitus) Consider • If minor trauma, further investigation not necessary except as for key points: – Oximetry if available – Blood tests – FBC – Blood gas analysis where applicable • Referral for ultrasound: renal, upper abdomen • Non-accidental injury continued … 10 Identifier Read Code Action Plan Closed Rib Fracture continued S120. continued • The main focus of treatment is maintaining active breathing – avoid splinting, taping, etc • Severe trauma: maintenance of airways, breathing, circulation • Tension pneumothorax – ring 111 • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Consider referring single, closed rib fractures if unable to cough, cannot clear secretions or significant co-morbidity, especially in the elderly • Encourage frequent deep breathing and coughing exercise • Support the chest with a pillow when coughing • Recommend patient returns to clinic if increased cough, respiratory difficulty or fever • Assess the level of independence and refer appropriately Onward Referral • All patients must be examined by a registered medical practitioner before they can be issued with a certificate for incapacity to work • Referral to medical practitioner if acute management of respiratory function required • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parents of young children Patient Education • Advise potential for pain to be worse in next few days with a gradual improvement • Explain importance of deep breathing exercises and closed rib fracture management 11 Closed and Non-Displaced Clavicle Fracture Identifier Read Code Key Points 12 Closed and Non-Displaced Clavicle Fracture S20.. • Clavicular fractures are common injuries • Nearly 50% of all clavicular fractures occur before 7 years of age as greenstick fractures • In neonates and children, clavicular fractures heal very well, whereas in adults the force required to cause a fracture is greater, therefore healing takes longer and the potential for complications is greater • It is almost impossible to immobilise displaced fractures; however, nonunion is rare • Displaced clavicle fragments can injure structures in close proximity because of the sharp edges of the fracture (major underlying vessels, the lungs and the brachial plexus) • Support for the weight of the arm is essential for the comfort of the patient • Immobilise the arm with a broad arm sling • Regular, adequate pain relief is required Classifications • Class A: middle third of the clavicle. Site of 80% of clavicle fractures • Class B: distal or lateral third of the clavicle. Site of 15% of clavicle fractures: – Type 1, non-displaced (the supporting ligaments remain intact with no significant displacement of the fracture fragments) – Type 2, displaced (the coracoclavicular ligament ruptures with resultant upward displacement of the proximal segment of the sternocleidomastoid muscle) – Type 3, articular surface (involving the AC joint) • Class C: proximal or medial third of the clavicle. Site of 5% of clavicle fractures Complications • Neurovascular injury • Injury to the underlying lung • Delayed union/non-union • Deformity (cosmetic implications) History • Comprehensive nursing assessment • Mechanism of injury: clavicular fractures can result from a fall onto the side or an outstretched arm. Most occur from a direct blow, or fall, onto the point of the shoulder Assessment (According to Competency) • Palpation along the length of the clavicle reveals an area of tenderness, perhaps swelling, crepitus, oedema and deformity • Ecchymosis can occur, especially when displacement causes tenting of the skin and/or if injury occurred a day or more ago • Neurovascular exam of the arm and hand is vital • Lung auscultation to clinically exclude pneumothorax according to competency or refer to medical practitioner • Assessment of the extent of injury and presence of signs and symptoms of complications Differential Diagnosis • AC injury • Dislocation of the shoulder • Fracture of the ribs • Pneumothorax/Tension and traumatic • R/C injuries • Sternoclavicular joint injury continued … Identifier Read Code Investigation Closed and Non-Displaced Clavicle Fracture continued S20.. continued X-ray: • AP shoulder girdle, AP clavicle with 15° cranial angulation • Apical lordotic views may be required to demonstrate the degree of displacement • Other tests may be necessary to assess the possibility of other injury associated with the fracture: – CXR if pneumothorax suspected Action Plan • Apply ice cold pack to the injury • Support for the weight of the arm • Undisplaced closed fractures will require a broad arm sling for 2 weeks • Appropriate referral for proximal fracture and suspected complications • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Onward Referral • All patients must be examined by a registered medical practitioner before they can be issued with a certificate for incapacity to work • Refer to GP or ED to exclude complications of fracture e.g. all closed fractures of the clavicle, multi-system involvement, open fracture, displaced fractures, suspicion of neurovascular damage • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Referral to a physiotherapist is generally not required. The elderly patient may acquire shoulder stiffness and require range of motion exercises • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children Patient Education • Education on use of the sling (see Resources: Practical Techniques in Injury Management Casts and Splints: ACC2373) • Report back to medical practitioner if changes develop e.g. swelling, skin breakage, loss of sensation in the hand or arm on the affected side • Educate to wriggle fingers, and gently move wrist, elbow and shoulder on the affected side frequently • Resume sport when fracture consolidated at approximately 3 months • Consider re-X-ray at 4-6 weeks for evidence of fracture union if pain persists. Children do not require re-X-ray • A lump may be obvious at fracture site. In children this usually resolves over 2-3 months, but in adults may always be present • Rest – reduces further damage, stop activity as soon as the injury occurs. Avoid as much movement as possible to limit further injury. Do not put any weight on the injured part • Ice – apply ice packs to the area – this cools the tissue and reduces the pain, swelling and bleeding. Place ice wrapped in a damp towel onto the injured area – do not put ice directly onto bare skin. Keep ice on injury for 20 minutes every 2 hours for the first 48 hours (not necessary to interrupt sleep for this) • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Continue regular analgesia until pain settles e.g. paracetamol, avoid NSAIDs 13 Closed Fracture Humerus, Proximal Shaft Identifier Read Code Key Points Red Flag cture in a child A humerus fra a trivial or ith presenting w ry should raise ju in nt te inconsis jury n-accidental in suspicion of no 14 Closed Fracture Humerus, Proximal Shaft S22.. • In children, greenstick fracture of the surgical neck is the most common type • Elderly patients are more prone to fracture due to osteoporosis • Consider pathological fracture • Non-displaced fracture of the greater tuberosity in children and adults can be managed in primary care: support, then mobilisation after 1–2 weeks • Impacted fractures of the neck of humerus are often missed Complications • Nerve injury: – Neuropraxia of the ulna nerve from inadequate padding over the medial epicondyle when applying the splint – Radial nerve – Axillary nerve – Brachial plexus • Avascular necrosis seen in fractures of the surgical neck of the humerus or multiple (3-4) part fractures • Problems maintaining the position of any cast • Joint stiffness, particularly in the elderly • Non-union of a shaft fracture History • Comprehensive nursing assessment • Mechanism of injury: by a direct blow to the arm or shoulder or fall onto an outstretched abducted arm or by axial loading through the elbow • Pathological fractures may occur with minimal trauma • Patients with a history of the following are most at risk of pathological fractures: – Metastatic cancer of the bone, Paget’s disease, osteoporosis, bone cyst • Pain • Oedema • Decreased range of motion Assessment (According to Competency) Proximal humeral fracture: • The proximal humerus has 4 parts: the joint surface, greater tuberosity, lesser tuberosity and humeral shaft – all should be examined radiologically for a fracture • Surgical treatment options are based on the number of segments involved and degree of displacement. If unsure of the classification, always discuss or refer to a medical practitioner • Note that in children the epiphyseal line is frequently mistaken for a fracture and vice versa Humerus shaft fracture: • Can be transverse, oblique or spiral and may require CT or MRI evaluation • Rarely occurs accidentally in children • Neurovascular examination of the affected limb – radial nerve damage following humeral fracture is relatively common • Pain occurs with palpation and/or movement of the shoulder or elbow (especially humeral rotation) • Ecchymosis is usually present continued … Identifier Read Code Differential Diagnosis Closed Fracture Humerus, Proximal Shaft continued S22.. continued • Dislocation of the shoulder • Fracture, clavicle • Fracture, elbow • Fracture, scapula • R/C tear • Pathological Fracture Investigation X-ray: • AP, lateral and +/– transthoracic and axillary views Consider: • Non-accidental injury Action Plan Initial treatment: • Monitor neurovascular status • Non-displaced fracture of the proximal humerus – immobilise • Arm support in a collar and cuff sling until the acute symptoms have resolved (1-2 weeks) • Under clothing often more comfortable • In children the collar and cuff may be adequate, consider U slab over the acromium for comfort • Consider sugar tong or U slab protection for adults for first 2 weeks • Commence mobilisation when acute symptoms resolved • Watch for late displacement (may need X-raying weekly for 4 weeks) • Displaced fracture refer for orthopaedic opinion • Need urgent referral to specialist if intra-articlar damage, open fractures, penetrating trauma, neurovascular damage, associated dislocation, additional fractures or comminuted fracture • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • In children: not generally necessary unless nerve paralysis • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy at approximately 6 weeks to ensure shoulder mobility, especially in the elderly • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment Patient Education • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up 15 Closed Fracture Distal Humerus, Supracondylar Identifier Read Code Key Points Closed Fracture Distal Humerus, Supracondylar S2241 • A supracondylar fracture of the humerus occurs just proximal to the bone masses of the trochlea, capitellum and often runs through the apices of the coronoid and olecranon fossae • The fracture line is generally transverse • Most common fracture of the elbow in children 3-11 years • 20-30% have little or no displacement, 20% are greenstick • Rare in adults, and they usually require surgical intervention Complications • Nerve injuries following a fracture can be as high as 12%. The most common is damage to the anterior interosseous branch of the median nerve • Arterial damage – brachial artery • Compartment syndrome and the sequelae – Volkmann’s contracture (atrophy and fibrosis when the brachial artery is compressed by a fracture of the lower end of the humerus) • Cubitus varus resulting from the initial fracture may lead to a gunstock deformity History • Comprehensive nursing assessment • Mechanism of injury: fall on an outstretched hand with an extended elbow which can cause posterior displacement • Always suspect when a child complains of pain in the elbow after a fall Assessment (According to Competency) • Tenderness and swelling over the distal humerus • Examine the wrist and shoulder on the affected side • Assess and document circulation as the brachial artery may be disrupted • Assess and document neurological status (the median nerve especially) at regular intervals i.e. 30 minutes depending on degree of swelling and any significant movement of the limb • The olecranon and medial and lateral epicondyles preserve their normal equilateral triangular relationship (unlike dislocation of the elbow) Differential Diagnosis • Dislocation of the elbow • Fracture forearm • Pulled elbow • Septic arthritis Investigation X-ray: • AP, lateral, oblique • Films of the other side should be taken for direct comparison if there is any doubt in interpretation • If study is performed to evaluate the elbow: AP, lateral, lateral tube angulated 45° continued … 16 Identifier Read Code Action Plan Onward Referral Closed Fracture Distal Humerus, Supracondylar continued S2241 continued In discussion with medical practitioner • Type 1: minimal or no displacement: – These are stable fractures which require splinting of elbow at 90° (for child’s comfort) – Provide adequate pain relief by prescription or standing orders – Long arm backslab and collar and cuff or broad arm sling with no less than 90° flexion, or as much as the circulation can tolerate without compromise – Elbow flexion greater than 90° may produce neurovascular compromise – Assess and document the neurovascular examination during and after treatment or any significant movement of the upper arm – Neurovascular compromise requires urgent specialist advice • Follow-up care Type 1: – In discussion with a medical practitioner – Re-X-ray at 7-10 days to exclude displacement – Assess union by tenderness and X-ray at 3-4 weeks for children, 6-8 weeks for adults – If satisfactory union, mobilise from a sling. Remove sling 3-4 times a day for 10 minutes and actively exercise. Discard sling when discomfort settles – Note any angulation and refer early if concerned – X-ray weekly if risk of displacement • Type 2: angulated fractures which are not completely displaced: – Require immediate referral to medical practitioner for orthopaedic assessment – The person should be hospitalised for potential neurovascular compromise • Type 3: completely displaced fractures: – Require immediate referral to medical practitioner for orthopaedic assessment – The potential for neurovascular injury and compartment syndrome is high • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Ensure all fractures have had examination by medical practitioner • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • Refer to physiotherapy at approximately 6 weeks to ensure shoulder mobility, especially in the elderly. Physiotherapy referral may not be required in children, although recovery of full elbow extension may take 3 months continued … 17 Identifier Read Code Patient Education 18 Closed Fracture Distal Humerus, Supracondylar continued S2241 continued • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred Fracture Proximal Radius and Ulna Identifier Read Codes Key Points Fracture Proximal Radius and Ulna S230./S231. • The majority of radial head fractures can be managed conservatively • Radial head dislocation/fracture can easily be missed • Hand dominance/occupation may affect management Complications • Fracture slipping; redisplacement or late angulation • Neurovascular injuries • Radial head fractures generally get good recovery of pronation/ supination but full extension may be long delayed History • Comprehensive nursing assessment • Mechanism of injury: fall on outstretched hand, direct blow to the elbow • Pain (location, radiation) Assessment (According to Competency) • Swelling, localised tenderness • Skin for open wound • Range of movement • Specific findings: – Radial head fracture – pain on pronation/supination – Olecranon fracture – decreased elbow extension • Neurovascular examination • Always examine elbow and wrist +/– shoulder Differential Diagnosis • Distal humerus fractures • Dislocation/Subluxation of proximal radio-ulnar joint • Ligamentous injuries around the elbow • Soft tissue injuries e.g. contusions to forearm • Dislocation of elbow • Pulled elbow in children Investigation X-ray: • AP, lateral, radio-capitellar • Both views should include the elbow and wrist on the films • Check anterior and/or posterior fat pad signs • It may be helpful to have comparison views of the other wrist continued … 19 Identifier Read Codes Action Plan Onward Referral Fracture Proximal Radius and Ulna continued S230./S231. continued Initial treatment: • RICE • Splint • Analgesia – by standing orders or prescription In discussion with a medical practitioner Fractures of the radial head and neck: • Radial head – non-displaced – sling, range of motion exercises after 7 days • Radial head – displaced/comminuted – refer to medical practitioner • Radial neck – undisplaced/angulated less than 15° – above elbow cast 3-4 weeks (child), 6-8 weeks (adult) • Radial neck – angulated more than 15° – refer to medical practitioner • Radial neck – comminuted/displaced – refer to medical practitioner • Slipped upper radial epiphysis – refer if displaced, otherwise put in POP for 3 weeks at 90° flexion Coronoid process fractures: • Fractures involving 50% or more of the process – refer acutely to medical practitioner • If less than 50% – in discussion with medical practitioner an above elbow cast. Mobilise at 3 weeks Fractures of the olecranon: • If undisplaced, above-elbow cast, discuss with medical practitioner for referral non-acutely for orthopaedic assessment • Refer all displaced fractures acutely for orthopaedic assessment • Non-operative fractures – start range of motion exercises after a few weeks Follow-up care: • Plaster check at 24 hours and plaster completed if a backslab has been applied • Clinical exam the next day should include assessment for neurovascular status and pain control • Follow-up X-ray at 7 days if potential instability • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Ensure all fractures have had examination by medical practitioner • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • Refer to physiotherapy at approximately 6 weeks to ensure shoulder mobility, especially in the elderly • May require referral to hand therapist continued … 20 Identifier Read Codes Patient Education Fracture Proximal Radius and Ulna continued S230./S231. continued • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred 21 Fracture Shaft Radius and Ulna Identifier Read Codes Key Points Fracture Shaft Radius and Ulna S232./S233. This includes: • Isolated fractures of middle 3rd of radius and/or ulna, including greenstick fractures in children • Galeazzi fracture dislocation (often missed) • Monteggia fracture dislocation (often missed) • Fractures of both radius and ulna shafts in adults and children • The outcome following forearm fractures in terms of function and bony union is related to the degree of trauma and type of fracture. It is optimised by early and appropriate treatment • Morbidity is high in missed/late diagnosis of open fracture or fracture plus dislocation • There is a higher frequency of morbidity from forearm fractures than from elbow or wrist fractures • In children most are greenstick • Treatment is largely determined by the amount of angulation and the amount of displacement • Hand dominance/occupation may affect management Complications • Fracture slipping; redisplacement or late angulation • Compartment syndrome • Neurovascular injury • Complex regional pain syndrome • Growth arrest • Radio-ulnar synostosis after delayed treatment • Axial malrotation may occur in fracture of the radius. Rarely present in fracture of the ulna History • Comprehensive nursing assessment • Mechanism of injury: indirect violence such as a fall on to an outstretched hand, direct blow to the arm Assessment (According to Competency) • Pain – location, swelling • Skin – open wound, tenting, infection (note high frequency of open fractures of forearm) • Neurovascular status • Deformity/angulation/displacement • Examine elbow and wrist always Differential Diagnosis • Dislocation of elbow or wrist • Fractures elbow/wrist • Contusions forearm Investigation X–ray: • AP, lateral • Other: – Include wrist and/or elbow in film – Must do separate elbow X-ray views because radio-ulnar dislocation often missed unless X-ray beam is centred on joint – Obliques as necessary continued … 22 Identifier Read Codes Action Plan Onward Referral Fracture Shaft Radius and Ulna continued S232./S233. continued Initial treatment: • RICE and splint • Analgesia – by standing orders or prescription In discussion with medical practitioner • If deformity exists that is threatening the overlying skin, it may be advisable to correct this with gentle repositioning of the limb, by referral to a medical practitioner for manipulation with analgesia Undisplaced non-angulated greenstick fractures in children: • Small child can be treated in an above-elbow backslab • An above-elbow POP cast is required where deformity has been corrected • Patient should have a broad arm sling or a collar and cuff • Child should be seen within 24 hours of the plaster application. Check neurovascular status • Compartment syndrome associated with these fractures – refer to medical practitioner urgently • In unstable fractures the position of the fracture should be X-rayed and checked each week for 3-4 weeks • Arm should remain in plaster for 4-6 weeks in 5-10-year-olds; and 3-5 weeks in 1-4-year-olds • Mobilisation should be started from a sling Undisplaced fracture of ulna and radius in adults: • Above-elbow POP for 6-8 weeks • All should be reviewed by orthopaedic surgeon • Compartment syndrome associated with these fractures – refer to a medical practitioner urgently • Plaster must be checked weekly for looseness and changed if necessary • Patients treated conservatively should have a broad arm sling, not a collar and cuff • Check position after 1 week with X-ray • After POP removal mobilise with an active exercise programme Isolated fracture ulna shaft (e.g. nightstick fracture): • Treat in above-elbow cast for 6-8 weeks in adult, 3-5 weeks for child if undisplaced • If >5 mm displacement or >10° angulation, refer for ORIF • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • In children: not generally necessary unless nerve paralysis • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy at approximately 6 weeks to ensure shoulder mobility, especially in the elderly • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment continued … 23 Identifier Read Codes Patient Education 24 Fracture Shaft Radius and Ulna continued S232./S233. continued • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred Fracture Distal Radius and Ulna Identifier Read Codes Key Points Fracture Distal Radius and Ulna S234./S235. This includes: • Isolated and combined distal radius and/or ulna fractures, adults and children • Colles’ type fractures • Smith’s type fractures • Growth plate injuries in children • Fractures of the distal radius and ulna are common in children (lower end of radius and ulna) • Reduction may be difficult • In adults, Colles’ fracture is common and often associated with fracture of the ulna styloid • Complications are common with Colles’ and Smith’s fractures • Hand dominance/occupation may affect management Complications • Fracture slipping; redisplacement or late angulation • Extensor pollicis longus rupture especially Colles’ • Subluxation/Dislocation of distal radio-ulnar joint • Ulnar nerve injury • Median nerve injury/carpal tunnel syndrome • Osteoarthritis • Growth arrest • Complex regional pain syndrome • Ulnar artery damage • Non-union, especially ulnar styloid fracture • Wrist joint ligament ruptures and/or triangular fibro-cartilage injuries associated with ulnar styloid fractures History • Comprehensive nursing assessment • Mechanism of injury: fall onto an outstretched hand, direct blow to the arm (rare) • Previous fractures in elderly Assessment (According to Competency) • Location of pain, swelling • Skin – open wound, tenting, infection (note high frequency of open fractures of forearm) • Neurovascular status • Deformity/Angulation/Displacement • Examine and document elbow, hand and wrist always Differential Diagnosis • Other fractures of the radius or the ulna • Fractures of the hand, elbow, forearm • Dislocations of wrist, elbow • Contusions of wrist, forearm, hand continued … 25 Identifier Read Codes Investigation Action Plan Fracture Distal Radius and Ulna continued S234./S235. continued X-ray: • AP, lateral • Other: – Include hand and/or elbow in film – Must do separate elbow X-ray views because radio-ulnar dislocation often missed unless X-ray beam is centred on joint – Obliques as necessary • If the study is performed to evaluate the distal forearm: – AP, lateral, 45° oblique • It may be helpful to have comparison views of the wrist Initial treatment: • Ice, elevate, splint • Analgesia – by standing orders or prescription In discussion with a medical practitioner • If deformity exists that is threatening the overlying skin, refer on to medical practitioner as it may be advisable to correct this with gentle repositioning of the limb, with analgesia administered Undisplaced greenstick fractures in children: • No reduction required if angulation less than 10° • Can be treated in a backslab or below-elbow cast unless >2cm from epiphysis (treat as mid-shaft fracture) • Patients should have a broad arm sling or collar and cuff • See within 24 hours of the plaster application. Check neurovascular status • In unstable fractures, the position of the fracture should be X-rayed and checked each week for 3-4 weeks. In stable fractures fortnightly checks should be adequate • The arm should remain in plaster for 4-6 weeks in 5-10-year-olds and 3-5 weeks in 1-4-year-olds • Mobilisation should be started from a sling Colles’ type fractures in adults: • Refer to medical practitioner to reduce under anaesthesia • Post reduction put in backslab or splint below-elbow plaster and review neurovascular status in 24 hours • Complete POP when swelling decreased and review at 1 week (re-X-ray) • Ensure patient mobilises fingers, elbow and shoulder regularly from the time of injury • Plaster must be checked weekly for looseness and changed if necessary • Patients treated conservatively should have a broad arm sling, not a collar and cuff • Weekly X-rays to check for early slipping for 2 weeks • After POP removal, mobilise with an active exercise programme • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately continued … 26 Identifier Read Codes Onward Referral Patient Education Fracture Distal Radius and Ulna continued S234./S235. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • In children: not generally necessary unless nerve paralysis • The patient, particularly the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to specialist physiotherapy following immobilisation • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred 27 Closed Fracture Scaphoid Identifier Read Code Key Points Closed Fracture Scaphoid S2401 • Often missed initially owing to the relative absence of pain • Predominantly an injury of young adults and adults (less common in children and the elderly) • Occurs frequently from a fall on an outstretched hand • Majority of clinically suspected scaphoid fractures will not be evident on X-ray but have to be treated as such due to the potential for avascular necrosis of the scaphoid (a severe and permanent disability) • In a true scaphoid fracture, tenderness will be present when pressure is applied over the dorsal and palmar aspects of the scaphoid. Tenderness in the anatomical snuffbox, while a very sensitive sign, is non-specific • Lunate dislocations may be missed on initial assessment • Initial X-rays often show no fracture: repeat views at 10-14 days are important. Bone scan also helpful • Delayed union, non-union and avascular necrosis are relatively common • Displaced fractures need referral Complications • Avascular necrosis of proximal fragment • Complex regional pain syndrome • Non-union seen at 3-6 months • Osteoarthritis History • Comprehensive nursing assessment • Mechanism of injury: direct significant force to outstretched dorsiflexed hand (axial loading from base of hand towards elbow) e.g. fall onto an outstretched hand (snowboarding) or kickback from an external source • A direct blow to the scaphoid area or a twisting injury to the wrist is highly unlikely to fracture the scaphoid and therefore does not need to be treated as a clinical scaphoid fracture if X-rays are normal • 1st presentation may be a number of days after injury Assessment (According to Competency) • Tenderness over the scaphoid tubercle, especially the dorsal and palmar aspects • Intolerance of dorsiflexion of the wrist • Tenderness in the anatomical snuffbox (although this is less specific) Differential Diagnosis • Bennett’s fracture of the thumb MC • Fracture of the radial styloid • Dislocations of the wrist • Tendonitis • Wrist sprain • Rupture of the scapho-lunate ligament continued … 28 Identifier Read Code Investigation Closed Fracture Scaphoid continued S2401 continued X-rays: • PA, PA with ulnar deviation, oblique 45°, lateral • Follow-up views at 14 days if clinical suspicion is high; repeat all 4 views • Additional scaphoid views may be useful: – PA ulnar deviation at 12° caudal – PA ulnar deviation at 30° caudal – PA ulnar deviation at 12° cranial • The fracture may be very difficult to visualise • An AP view with the wrist in ulnar deviation may make the fracture more apparent • X-rays may or may not confirm a fracture, even if there is strong clinical suspicion • A bone scan is an excellent and cost-effective investigation to confirm or rule out a scaphoid fracture when suspected clinically with normal X-rays. It is likely to save the patient 2 weeks of time off work and unnecessary cast immobilisation Action Plan • Because of the likelihood of complications with this fracture, refer and discuss with a medical practitioner • Clinically suspected (signs and symptoms above) but normal X-ray: – Scaphoid plaster 10-14 days, then repeat X-rays after removal of plaster • X-ray-proven undisplaced fracture: – Scaphoid plaster 6 weeks: check at 24 hours and 2 weeks – At 6 weeks remove plaster, assess clinically and repeat scaphoid views – If the fracture appears united on X-ray (this is rare) and there is no tenderness over the dorsal surface or at the snuffbox, the plaster should be removed and the wrist checked in 2 weeks – If the fracture is still present on X-ray or indicates union, but there is continued tenderness, re-apply the plaster for another 4 weeks, then remove, X-ray and re-examine – Refer early if uncertain about management or concerned about progress • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • Orthopaedic referral if hand function has not improved after normal healing time • In children: not generally necessary unless nerve paralysis • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to specialist physiotherapy following immobilisation • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment continued … 29 Identifier Read Code Patient Education 30 Closed Fracture Scaphoid continued S2401 continued • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Advice to return to medical practitioner if not gained function after removal of plaster • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred Fracture Carpal Bone (No Other Symptoms) Identifier Read Code Key Points Fracture Carpal Bone (No Other Symptoms) S24Z. • The function of the hand, especially gripping, is dependent on the stability and integrity of the carpal bones and ligaments • There are 8 carpal bones arranged in 2 rows • The motion of the wrist occurs between the radius and carpal bones • The major types of injury include fractures of the carpal bones, dislocations and fracture/dislocations • Because of the potentially serious consequences of these types of injury, always document the neurovascular status of the hand at initial examination and at regular intervals • A fall onto an outstretched hand is the primary mechanism • Usually requires rest in plaster • Carpal instabilities may develop early or late after a carpal injury • The more energy involved in the injury, the higher the likelihood that there will be severe injury even in the presence of a normal X-ray • Major ligament injuries, bone surface injuries and triangular fibrocartilage injuries are frequently missed because wrist injuries with normal X-rays are dismissed as sprains • Hand dominance/occupation may affect management Complications • Ulnar nerve palsy may occur with fractures of the hamate and pisiform • Carpal instabilities may develop early or late after a carpal injury • Median nerve damage is associated with lunate dislocation and perilunate fracture and is manifested by sensory disturbances in the thumb, index and long fingers History • Comprehensive nursing assessment • Mechanism of injury • Dislocations: – Lunate/Perilunate – usually the result of extreme flexion/extension injuries of the wrist. These require urgent assessment by a medical practitioner and treatment with ORIF • Fractures: – Fracture lunate – dorsiflexion injury or impact of the heel of the hand with a hard surface – Fracture capitate – 15% of all carpal bone fractures – Caused from direct blow or fall onto hard surfaces with the hand in dorsiflexion and are often associated with other injuries – Small chip fractures of the carpus are common and generally result from hyperflexion or hyperextension injuries of the wrist – Fractures through the bodies of the carpal bones except the scaphoid are rare continued … 31 Identifier Read Code Assessment (According to Competency) Fracture Carpal Bone (No Other Symptoms) continued S24Z. continued • Dislocation (lunate/perilunate): – Pain is usually severe and located on the dorsal or volar aspect of the wrist over the lunate – Movement causes pain – Wrist deformity and swelling • Fractures: – Although ecchymosis is not always present, oedema and point tenderness may indicate a fracture – A thorough range of motion examination with pronation and supination to document pain and limitation of movement – Lunate fractures are associated with point tenderness over the lunate fossa • Because of the potentially serious consequences of these types of injury, always document the neurovascular status of the hand at initial examination and at regular intervals e.g. 30 minutes depending on the swelling and following procedures or significant movement of the hand Differential Diagnosis • Triangular fibrocartilage injuries • Chondral fractures • Major ligament injuries • Fractures of the forearm • Dislocations of the wrist • Tendonitis • Scapholunate instability Investigation X-rays: • The majority can be adequately assessed by good AP and lateral. On the lateral X-ray 11° of palmer angulation of the articular surface is normal • Consider scaphoid views, clenched fist AP views • Consider bone scan for occult fracture Action Plan In discussion with medical practitioner • Initial treatment: – Urgent reduction of a fracture (or dislocation) is necessary when the neurovascular status is compromised. Refer promptly to a medical practitioner for reduction – Lunate fractures often associated with wrist ligament injury. Splint the wrist and refer to medical practitioner for orthopaedic evaluation in 2-4 days – Rest small chip fractures of the carpus in plaster for 3 weeks – Rest undisplaced fracture through the body of a carpal bone for 6 weeks in a Colles or scaphoid plaster with check X-ray at 1 week – Refer immediately to medical practitioner if fracture displaced – Peri-lunate and peri-scapholunar dislocations of the carpus require immediate referral to a medical practitioner then specialist management • Follow-up care: – Check POP at 24 hours – Check X-ray in POP at 1 week • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately continued … 32 Identifier Read Code Onward Referral Patient Education Fracture Carpal Bone (No Other Symptoms) continued S24Z. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • Ensure specialist review if nerve damage present • Orthopaedic referral if hand function has not improved after normal healing time • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Physiotherapy may be required to mobilise the wrist after full period of immobilisation • Consider specialist physiotherapy (hand clinic) • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Advice to return to medical practitioner if not gained function after removal of plaster • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred 33 Fracture Metacarpal Bone Identifier Read Code Key Points Fracture Metacarpal Bone S25.. • Terminology varies but it is best to refer to MCs as relating to fingers e.g. thumb MC, index MC, middle MC, ring MC, little MC • This code includes fractures to head, neck, shaft and base of each MC (plus Bennett’s, Rolando’s and some Gamekeeper’s fractures) • Hand dominance/occupation may affect management • Fractures involving a punch to the mouth carry the risk of oral bacteria • Prophylactic antibiotics may be required for open fracture Complications • Loss of functioning e.g. hand stiffness, is the most common • Delayed/Mal-union • Avascular necrosis • Post-traumatic arthritis • Complex regional pain syndrome History • Comprehensive nursing assessment • Mechanism of injury and likelihood of foreign body Assessment (According to Competency) • Compare with uninjured hand and document: – Skin/Soft tissue injury e.g. crushing, bruising, lacerations, deformity, foreign body – Location of tenderness – Hand function should dictate management • Function: – Range of motion of hand; CMC joints, fingers – Neurovascular status – Mal-rotation of fingers, shortening • Interpret X-rays in discussion with medical practitioner with regard to: – Fractures – site, angulation, rotation, displacement, number, relation to joint surfaces, stability – Presence or absence of related injuries e.g. air, foreign body, infection – Acceptable angulation in MC neck fractures: If not rotated and stable: » <15° for index and middle MCs » <30° for the ring and little MCs – Acceptable angulation in shaft fractures: » <10° in index and middle MCs » <20° in ring and little MCs – At least 50% bony contact is required Differential Diagnosis • Wrist fractures/dislocations • Metacarpophalangeal dislocation • Contusions/Sprains Investigation X-ray: • Thumb MC – AP, lateral • Index to little MCs – PA, 45° (oblique), Lateral • Compare with uninjured side if required • Scrutinise points of insertion of ligaments and tendons and the alignment of articular surfaces continued … 34 Identifier Read Code Action Plan Onward Referral Fracture Metacarpal Bone continued S25.. continued • Initial: ice, elevate, splint, analgesia In discussion with a medical practitioner • If there is no significant soft tissue damage, the fracture is in an acceptable position and the fracture is stable: – Elevation of the arm in a broad arm sling – Mobilise early MC head fractures: • Refer acutely or discuss with a medical practitioner all fractures that are undisplaced and those that are complicated (displaced, comminuted, tendon injury, mal-rotation, foreign body, infection, joint surfaces involved, air, unstable) MC neck fractures: • Refer acutely or discuss with a medical practitioner all fractures • Often occur after direct blow (note all little MCP fractures are boxer’s fractures until proven otherwise) • Refer acutely or discuss all fractures with medical practitioner MC base: • Refer acutely or discuss with a medical practitioner all fractures • Index, middle (uncomplicated) – splint as appropriate e.g. volar POP/ splint 5-10 days, mobilise early • Index, middle (complicated) – discuss and/or refer • Ring – refer acutely or discuss (often associated with subluxation of CMC joint) • Thumb (Bennett’s or Rolando’s fracture) – refer all to medical practitioner Mid-shaft fractures: • Refer acutely or discuss with a medical practitioner all fractures • Uncomplicated e.g. stable solitary fracture, no rotation, no shortening and acceptable angulation: rest on volar slab 5-10 days, mobilise • Complicated – refer or discuss acutely • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • Orthopaedic referral if hand function has not improved after normal healing time • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and a social rehabilitation assessment • Consider specialist physiotherapy (hand clinic). continued … 35 Identifier Read Code Patient Education 36 Fracture Metacarpal Bone continued S25.. continued • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Advice to return to medical practitioner if not gained function after removal of plaster • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred Fracture Phalanges Hand Identifier Read Code Key Points Red Flag hand function of the The position of e IP th ith w is rposes for splinting pu ints jo CP M n, io extens joints held in at ed wrist dorsiflex at 90° and the . n) ” positio 45° (the “cobra Fracture Phalanges Hand S26.. • Much of the morbidity and disability can be prevented if proper management begins early • Do not underestimate fractures in children. Remodelling can occur only in those fragments angulated in the line of the pull of the tendons. Lateral angulation and rotational mal-alignment, not obvious on X-ray, will never remodel and require accurate reduction • If angulation is greater than 10°, refer for reduction • Internal fixation or traction splinting if the fracture is unstable • Mobilise early to avoid stiffness. From 7 to 14 days is ideal • Reduction by a medical practitioner can be performed under an ulna nerve block or mixed median/radial nerve block as required • Where possible, referrals should be to a hand surgeon/orthopaedic surgeon • Hand dominance/occupation may affect management Complications • Finger stiffness due to joint adhesions is the most common and can result in permanent loss of range of motion and function • Infection from open fractures • Mal-union • Mallet finger History • Comprehensive nursing assessment • Establish mechanism and force of injury – Axial compression from ball versus fingertip – Rotational injury – Crush injury • Potential compound wound • Joint injury • Social and occupational activity Assessment (According to Competency) • Compare with the uninjured side • Note erythema, ecchymosis and swelling • Check vascular status by noting capillary refill • Assess the extent of nerve, tendon or skin loss • Assess neurovascular status prior to administration of local anaesthetic or regional block • Determine the exact location of tenderness • Assess the degree of displacement, stability and any rotational deformity • Examine unaffected fingers and wrist Differential Diagnosis • Sprains of the fingers • Lateral subluxation of finger • Avulsed tendons or damaged tendons (e.g. extensor hood damage causing boutonnière deformity, or extensor avulsion causing mallet finger) • Volar plate injury • Missed dislocations of the IP joints continued … 37 Identifier Read Code Investigation Action Plan Fracture Phalanges Hand continued S26.. continued X-rays: • AP, 45° oblique, lateral • Compare with uninjured side if required • Scrutinise points of insertion of ligaments and tendons and the alignment of articular surfaces In discussion with medical practitioner • Plastering guide (see Practical Techniques in Injury Management: Casts and Splints: ACC2373) • Control swelling by rest, ice and elevation • Immobilise including proximal and distal joints to the fracture • Potentially compound wounds require surgical intervention, prophylactic antibiotics and tetanus booster • Internal fixation may be necessary: for angulation, unstable or fractures extending into the articular space Fractures of the proximal and middle phalanges: • Refer acutely or discuss with a medical practitioner all fractures • Non-displaced and stable fractures of the shaft, base, neck, intercondylar region or epiphyseal injuries: – Should have splint applied for 1-3 weeks and checked at weekly intervals – If symptoms are marked, apply a Zimmer splint (in position of function) – Re-examine and re-X-ray in 1 week to ensure no displacement (if any concerns refer early to hand specialist) • Seek advice for any displaced fractures, angulated fractures, compound fractures, growth plate injuries, and fractures extending into a joint • The MC joint should never be fixed in extension Fractures of the terminal phalanx (the neck and the base): • Refer acutely or discuss with a medical practitioner all fractures • Most common injury is a comminuted fracture of the terminal tuft. There is usually no angulation or displacement. Associated subungal haematomas may be treated with trephination (antibiotics are usually not required) • For displaced or angulated fractures, seek advice early • Prioritise soft tissue injury treatment • Pain relief may be gained by strapping the finger to a spatula or using a plastic finger splint • Fractures or fracture/dislocations at the base of the terminal phalanx can lead to mallet finger deformity. Therefore test the power of extension at the DIP joint. If there is a possibility of a mallet finger, splint DIP joint in full extension for 8 weeks, seek advice early if unsure. Tell the patient that the finger must at all times be held in full extension to help prevent a permanent disability • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately continued … 38 Identifier Read Code Onward Referral Patient Education Fracture Phalanges Hand continued S26.. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Any complication e.g. neurovascular or angular changes should be referred to an appropriate specialist via a medical practitioner • Orthopaedic referral if hand function has not improved after normal healing time • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Ensure specialist review if nerve damage present • Refer to specialist physiotherapy following immobilisation • If dominant hand, may require assistive devices and work site modification, social rehabilitation assessment • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and use of sling • Instruct on maintaining mobility of fingers and unaffected joints • Advice on exercise of the adjacent joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Advice to return to medical practitioner if not gained function after removal of plaster • Arrange appropriate follow-up, and ensure the patient has the contact details of those to whom they have been referred 39 Fracture Tibia and Fibula Ottawa Knee Rules Pittsburgh Knee Rules X-ray if: Indicate radiography if the mechanism of injury is blunt trauma or a fall, and either: • • • • • Patient >55 years Tenderness present at head of fibula Isolated tenderness over patella Inability to flex knee to 90° Inability to transfer weight for 4 steps both immediately after injury and at examination Exclusion criteria: • Age <18 years • Isolated superficial injuries being re-evaluated • Patients with altered levels of consciousness, paraplegia or multiple injuries Identifier Read Code Key Points Red Flag arus ens to valgus/v If the knee op is th lly extended, stress while fu ar of te ar ul erior caps implies a post d. rre fe re be should the knee and 40 • The patient is <12 or >50 years of age; or • The injury causes an inability to walk 4 weightbearing steps at examination Exclusion criteria: • Knee injuries that occur more than 6 days before presentation • Patients with only superficial lacerations and abrasions • Those with a history of previous surgeries or fractures on the affected knee • Reassessments of the same injury Fracture Tibia and Fibula S33.. • Fractures of the tibia are often associated with fractures of the fibula, although isolated fractures of either can occur • Ensure X-ray visualisation of the whole length of the fibula before diagnosing an isolated tibia fracture • Fractures are often open because of the length of the tibia, which is in close proximity to the skin • Admission may be necessary for elevation, pain relief, monitoring of the circulation • Often require internal fixation • Toddler’s fracture is a distal spiral fracture of the tibia most common in the age group 9 months to 3 years • Suspect non-accidental injury (in children) with mid-shaft fractures of the tibia unrelated to history of significant trauma • Follow-up is important during the first 3-4 weeks post injury Complications • Delayed union or non-union due to limited blood supply in lower half of tibial shaft • Fat emboli • Compartment syndrome • Infection in compound injury • Peroneal nerve injury with associated foot drop History • Comprehensive nursing assessment • Mechanism of injury: direct blow or angulatory force applied to leg. Usually due to considerable force, and often associated with other injuries; indirect force e.g. rotational strain which causes spiral fractures; falls from a height onto feet • Past history of trauma/vascular problems/DVTs Symptoms: • Pain and swelling at injury site • Inability to weight bear continued … Identifier Read Code Assessment (According to Competency) Fracture Tibia and Fibula continued S33.. continued • Check the whole leg • Note any deformity, ecchymosis, point tenderness, oedema and crepitus • Examine for loss of skin integrity. Treat any wound as compound injury • Assess neurovascular status, pain, pallor, paraesthesia • Palpate and mark pedal pulses: the popliteal artery is vulnerable to damage in displaced upper tibial fractures • Ability to walk (isolated fibula fractures are able to walk) Differential Diagnosis • Ankle, soft tissue injuries • Compartment syndrome, extremity • Fracture, knee (tibial plateau), ankle • Paediatrics, non-accidental injury • Peripheral vascular injuries • Tendonitis Investigation X-ray: • Recommended X-rays: AP, lateral • Both views should include the knee and ankle joint • In all cases of fracture of the tibia in high-energy accidents, it is essential to check hip clinically and X-ray • X-ray the length of the leg to ensure fractures at other sites are ruled out • Consider a bone scan for suspected stress fractures continued … 41 Identifier Read Code Action Plan Follow-Up Treatment Fracture Tibia and Fibula continued S33.. continued Initial treatment: • Airways, breathing, circulation • Splint the affected leg if transporting (Practical Techniques in Injury Management: Casts and Splints: ACC2373) • Patient may need to be admitted for rest and elevation • Check and document neurovascular status • Compound injury will require hospital management – urgent referral • Comminuted or displaced fractures require immediate hospital management In discussion with medical practitioner • Compound fractures: – Immediate antibiotics – Orthopaedic assessment – Tetanus – Post-discharge wound care/observation • Comminuted and displaced fractures: – Orthopaedic assessment – Likely require ORIF – Post-surgical wound observation/dressing and care • Non-displaced, closed tibia fractures in adults: – Apply a long leg plaster – Re-check X-rays of the limb. The knee should be at 5-10° flexed – Split the cast and review indications for admission – Patient should be able to mobilise the next day – non-weight bearing and crutches – Complete cast after 3-7 days – Patient should be seen weekly with X-rays and for review of the cast – Avoid full replacement of the cast until 3-4 weeks when the fracture is more stable – Partial weight bearing may commence when swelling settled (about 7-10 days) • Non-displaced closed tibia fractures in children: – As above, POP backslab or split-cast, above knee, non-weight bearing for 1 week – At 1 week, re-X-ray for position, replace cast only if necessary and encourage weight bearing as tolerated – If there was any displacement, X-ray at 2 weeks and review at 4-6 weeks depending upon age – Complete pain assessment and provide adequate pain relief by standing orders or prescription – Assess the level of independence and refer appropriately • Wound care (post-op wounds require 2 weeks of monitoring). Check for signs of infection • Plaster care and checks (pain, itchiness, condition of the cast) • Neurovascular observation (pulse, nerve function, skin integrity intact). Refer on if complications suspected, especially DVT, compartment syndrome, infection or neurovascular compromise • Note any change in sensation of the foot or leg (seek medical advice) • Note any change in the temperature of the foot or toes i.e. goes cold and pale (seek medical advice) • Referral to GP or ED if any complications suspected continued … 42 Identifier Read Code Onward Referral Patient Education Fracture Tibia and Fibula continued S33.. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Refer to GP or ED if complications suspected e.g. neurovascular compromise, compartment syndrome, intolerance of cast • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • Refer to physiotherapy to maintain range of movement of unplastered joints (ankle and subtalar joints may become stiff), and also refer when plaster removed • The patient, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • The elderly may require assistive devices while in POP and on crutches • Parents with dependent children will require assistance e.g. home help, child care, while on crutches • Refer to paediatrician if suspected non-accidental injury • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Seek immediate medical attention if they experience any signs of circulatory or nerve compression: – Inability to extend the toes fully – Pain on gentle extension of the toes – Any change in the colour of the toes e.g. white, blue, red or purple – Any change in the sensation of the foot or leg – Any change in the temperature of the foot or toes i.e. goes cold and pale – Persistent pain (greater than one would normally expect for the given injury) • Educate about signs and symptoms of infection: local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Educate about untoward swelling – advise patient what to expect and when to return • Explain pain medications – keeping up with regular paracetamol avoiding all NSAIDs, and reporting escalating pain • Teach about care of cast • Instruct on maintaining mobility of toes and unaffected joints • Encourage regular quadriceps exercises • Educate on the reasons for restricting exercise and the timeframe to resume activity • Advise and explain about rest • Avoid HARMS • Arrange appropriate follow-up • Teach and explain about elevation • Each injury will have different timeframes for weight bearing. Explain the different orthopaedic recommendations • Instruct on the use of crutches 43 Fracture Ankle Identifier Read Code Key Points Rules Ottawa Ankle who are: X-ray patients ring ke 4 weight-bea ta • Unable to n io at in am ex steps at time of at distal end of or nd hi be er • Tend us. either malleol ures. calcaneal fract e Does not includ Fracture Ankle S34.. • Ankle fractures can result from eversion, inversion and external rotation injuries • The most common ankle injury is when the talus is rotated in the mortise, fracturing 1 or both malleoli • Excellent results from conservative treatment can be obtained in the majority of ankle fractures • Internal fixation should be considered in the presence of significant diastasis or unstable bimalleolar or trimalleolar fractures • Undisplaced single malleolus fractures can be managed in a POP cast for 4-5 weeks • Delay in treatment increases the risk of complications • Diligent follow-up is required Complications • Open fractures have a high risk of infection • Swelling persisting for weeks or months after fracture union is very common • Reflex sympathetic dystrophy or complex regional pain syndrome • Instability due to lateral ligament ruptures may occur • Post-traumatic osteoarthritis • Osteochondral fractures; re-X-ray and refer if ankle not clinically improving after appropriate treatment History • Comprehensive nursing assessment • Understanding the mechanics of the injury may aid in diagnosis and treatment • Can involve severe trauma or subtle trauma (e.g. stepping from a kerb causing sudden pain in an elderly patient) Assessment (According to Competency) • Check neurovascular status (posterior tibial pulse, dorsalis pedis pulse and capillary return) • Examine the joint and lower limb carefully • Note presence of haemoarthrosis, any changes in the relation of the foot to the ankle, any deformity, swelling or bruising, any point tenderness, discolouration, temperature (especially cold) and inability to weight bear – these are all indicators of a fracture and need to be X-rayed Differential Diagnosis • Ankle sprain • Ankle dislocation • Fracture, foot • Fracture, tibia • Lateral or medial ligament injury Investigation X-ray: • AP, mortise view and lateral • The whole fibula should be examined. High shaft fractures can be associated with ligament damage at the ankle • If in doubt about ligament integrity, stress films may be helpful • X-rays should include base of 5th MT if tenderness or pain localised to lateral aspect of the foot continued … 44 Identifier Read Code Action Plan Types: Ankle Fracture Weber Type A: elow ular avulsion (b Transverse fib ese Th . e) e joint lin horizontal ankl d an n tio ta ro rnal result from inte able. st lly ua Us s. rie adduction inju Weber Type B: olus, e lateral malle Oblique fractur e th of e t ruptur with or withou edial esmosis and m nd sy ar ul tibiofib l ia (either med ligament injury ament e or deltoid lig ur ct fra malleolar ternal e result from ex rupture). Thes er th ei ries and are rotational inju . le ab st un tentially unstable or po Weber Type C: ure cture with rupt High fibular fra rse ar and transve of the tibiofibul l ia ed e of the m avulsion fractur ion or ct du ad m lt fro malleolus. Resu n. external rotatio abduction with Follow-Up Treatment Fracture Ankle continued S34.. continued • Urgent referral to a medical practitioner when the neurovascular status is compromised • Stabilise and elevate limb, splint securely – this may require reduction of the deformity by a medical practitioner • Practical Techniques in Injury Management: Casts and splints: ACC2373 In discussion with medical practitioner • Undisplaced single malleolus fractures: – Discuss or refer Weber B or C fractures to a medical practitioner – BKPOP non-weight bearing for 2 weeks then weight bearing for 4 weeks on orthopaedic advice – Check POP after 24 hours – Crutches – Follow up and re-X-ray after 1 week (and fracture clinic review) – Further weekly follow-up is required for up to 3 weeks, with assessment of the need for re-application of the plaster – Supportive elastic bandaging after the POP is removed – Replace POP if loose or breaking up (risk losing the reduction) – Isolated stable lateral malleolus and tibial fractures may not require POP (discuss with specialist if unsure) – Compound fractures require urgent referral to orthopaedic service as likely to require admission – Comminuted fractures – require orthopaedic/ED referral and are likely to require ORIF • Avulsion fractures (Weber A): – May not require cast. Be guided by the degree of discomfort – An airsplint may be adequate – A below-knee cast or backslab is a good option for 1 week to control pain and excessive movement which may exacerbate swelling – Complete pain assessment and provide adequate pain relief by standing orders or prescription – Assess the level of independence and refer appropriately • Wound Care (post-op wounds require 2 weeks of monitoring). Check for signs of infection • Plaster care and checks (pain, itchiness, condition of the cast) • Neurovascular observation (pulse, nerve function, skin integrity intact) Refer on if complications suspected, especially DVT, compartment syndrome, infection or neurovascular compromise • Note any change in sensation of the foot or leg (seek medical advice) • Note any change in the temperature of the foot or toes i.e. goes cold and pale (seek medical advice) • Referral to GP or ED if complication suspected • Review pain assessment, consider referral • Review psychosocial health, consider referral continued … 45 Identifier Read Code Onward Referral Patient Education 46 Fracture Ankle continued S34.. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Refer to GP or ED to exclude complications • Refer to physiotherapy for rehabilitation post removal of plaster. May require gait re-education. Physiotherapy is generally required for displaced fractures, also refer for any persistent swelling, weakness or stiffness • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • The patient, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to counselling or psychologist if appropriate • In children: not generally necessary to refer on unless nerve paralysis • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Seek immediate medical attention if they experience any signs of circulatory or nerve compression: – An inability to extend the toes fully – Pain on gentle extension of the toes – Any change in the colour of the toes e.g. white, blue, red or purple – Any change in the sensation of the leg – Any change in the temperature of the leg and foot i.e. goes cold and pale • Educate about signs and symptoms of infection: local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Educate about untoward swelling – advise patient what to expect and when to return • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast • Advise limitations of exercise and educate on the reasons for restricting exercise and the timeframes • Educate how to remain active and maintain mobility of unaffected joints • Encourage gait and muscle strengthening exercises and regular quadriceps exercises • Advise and explain about rest • Avoid HARMS • Arrange appropriate follow-up • Instruct on the use of crutches Closed Fracture Other Tarsal/Metatarsal Identifier Read Code Key Points Closed Fracture Other Tarsal/Metatarsal S352. This code includes: • MTs 1-5 fractures • March fracture is a stress fracture of 2nd or 3rd MT • Lis-Franc fracture is fracture/dislocation of the foot where 1 or more of proximal MTs are displaced • Talus fractures are significant in that the blood supply is poor and healing difficult • Navicular fractures • Os calcis fractures (calcaneum). Often associated with spinal injury • Fracture of the 5th MT is the most common fracture (most often due to an inversion injury) Complications • Gait disturbance • Compartment syndrome (a potential serious complication of a crush fracture of the foot ) • Non-union (especially base 5th MT) • Avascular necrosis (talar neck, navicular body) • Complex regional pain syndrome (Lis-Franc) • Post-traumatic arthritis (Lis-Franc) History • Comprehensive nursing assessment • Mechanism of injury: inversion e.g. base 5th MT, crushing e.g. MTs 2-4, twisting/torsion e.g. Lis-Franc, fall from height onto feet e.g. os calcis (often associated spinal injury), snowboarding e.g. lateral process of talus • Sensory and circulation change since fracture Assessment (According to Competency) • Compare with the other foot • Observe for bruising, swelling, deformity, lacerations/open wounds • Palpate – site of tenderness • Assess weight bearing/gait • Record objective signs of neurovascular status • Assess range of motion of all joints Differential Diagnosis • Sprain e.g. ankle, MTP joint • Dislocation e.g. subtalar • Contusions foot/ankle • Other conditions such as arthritis, gout Investigation X-ray: • Recommended X-rays: foot: – AP (dorsiplantar), oblique, lateral • If the study is to evaluate the mid-foot: – Coned AP mid-foot, coned oblique mid-foot, lateral foot • If the study is to evaluate the calcaneus: – Lateral hind-foot, tangential view (axial) hind-foot • With the multiple growth centres in children it may be helpful to have view of the uninjured foot continued … 47 Identifier Read Code Action Plan 48 Closed Fracture Other Tarsal/Metatarsal continued S352. continued In discussion with medical practitioner • Urgent referral to orthopaedic assessment indicated for suspected open fractures, fracture dislocations, displaced or angulated fractures, os calsis fractures, talar dome fractures, multiple MT fractures and comminuted fractures • Undisplaced fractures of single MTs, undisplaced talar and navicular fractures, and minor avulsion fractures of os calsis may be treated with BKPOP • Check POP after 24 hours • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately • Rest, ice and elevation of the limb • Maintain neurovascular observation • Gait training with use of crutches Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Refer to GP or ED to exclude complications (suspected open fracture, compartment syndrome, nerve compression, compromise of circulation) • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • All patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy once out of POP to ensure mobility • In children: not generally necessary to refer on unless nerve paralysis • Early referral for pain management may be indicated Patient Education • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Seek immediate medical attention if they experience any signs of circulatory or nerve compression: – An inability to extend the toes fully – Pain on gentle extension of the toes – Any change in the colour of the toes e.g. white, blue, red or purple – Any change in the sensation of the leg – Any change in the temperature of the leg and foot i.e. goes cold and pale • Educate about signs and symptoms of infection: local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Educate about untoward swelling – advise patient what to expect and when to return • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of cast and the use of crutches • Instruct on maintaining mobility of unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up Closed Fracture Phalanges Foot Identifier Read Code Key Points Closed Fracture Phalanges Foot S36.. • Toe fractures nearly always heal with very little treatment • Fractures in children are more difficult to recognise because of the multiple growth centres • Ensure fracture will heal in shape to fit comfortably into a shoe Complications • Infection • Non-union • Gait disturbances • Arthritis • Inability to fit into shoes History • Comprehensive nursing assessment • Establish mechanism and force of injury: common fractures in men, often caused by a heavy object dropped onto the foot; the big or little toes stubbed on an immovable object is another cause Assessment (According to Competency) • Compare with the other foot • Assess weight bearing/gait • Look for bruising, swelling, deformity, lacerations/open wounds • Palpate – site of tenderness • Record objective signs of neurovascular status • Range of motion of all joints – IP, MTP • Associated structures e.g. tendon power Differential Diagnosis • Toe dislocations • Contusions/Sprains • Tendon injuries • MT fractures • Other conditions arthritis, gout, infection and chilblains Investigation X-ray: • AP, oblique, lateral Action Plan Initial treatment: • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Rest, ice and elevation of the limb • Buddy splint the broken toe to the adjacent toe with gauze pads between toes • Consider managing by wearing a stout shoe with the toe cut out for comfort or an orthopaedic shoe In discussion with medical practitioner Great toe fractures: • Undisplaced: splint + crutches. Consider BKPOP with toe platform • Displaced: refer acutely for orthopaedic assessment Toes 2-5: • Undisplaced: buddy splint as above +/– crutches • Displaced or angulated, especially little toe: refer acutely for orthopaedic assessment to reduce if significant deformity, under local block, splint as above continued … 49 Identifier Read Code Onward Referral Patient Education 50 Closed Fracture Phalanges Foot continued S36.. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Refer to GP or ED to exclude complications such as suspected open fracture, displaced great toe fracture, displaced 5th toe fracture, suspected foreign body or tendon injury • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Educate how to self-assess for signs of circulatory or nerve compression, or infection • Seek immediate medical attention if they experience any signs of circulatory or nerve compression: – An inability to extend the toes fully – Pain on gentle extension of the toes – Any change in the colour of the toes e.g. white, blue, red or purple – Any change in the sensation of the leg – Any change in the temperature of the leg and foot i.e. goes cold and pale • Educate about signs and symptoms of infection: local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Educate about untoward swelling – advise patient what to expect and when to return • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of the splint and the use of crutches • Instruct on maintaining mobility of unaffected joints • Advise limitations of exercise • Advise rest • Avoid HARMS • Arrange appropriate follow-up Dislocation/Subluxation Shoulder Identifier Read Code Key Points Dislocation/Subluxation Shoulder S41.. • 1st time dislocations cause severe pain and decreased range of motion and follow history of trauma, but subsequent or recurrent dislocations may be much less painful • Anterior dislocations account for 95% of shoulder dislocations • The key to a successful reduction is slow but steady manipulation with adequate analgesia and relaxation • The rate of recurrence is high, particularly in the under-20-year age group • Children are more likely to fracture the proximal humerus • Patients over 40 years have a high incidence of complete rupture of the supraspinatus tendon Complications • Axillary nerve palsy is the most common neurological complication • Recurrence • R/C tear • Associated fractures e.g. greater tuberosity, Hill-Sachs, Bankart lesions • Vascular injury, axillary artery most common History • Comprehensive nursing assessment • Mechanism of injury: – Anterior dislocations are caused by abduction, external rotation and extension. Falls onto an outstretched hand a common cause in older adults – Posterior dislocations are caused by severe internal rotation and adduction usually during a seizure or fall on an outstretched arm and occasionally by a direct blow or electric shock – Inferior dislocations usually caused by indirect forces hyper-abducting the arm • History of significant trauma unless recurrent • Full history – prior dislocation, mode of injury • Symptoms of circulation or sensation change Assessment (According to Competency) • Compare vascular status with the opposite arm Anterior: • Look for loss of normal shoulder contour compared to other side • The humeral head may be felt lying anteriorly and inferiorly to clavicle and coracoid process • Arm held slightly abducted and externally rotated • Neurovascular assessment – note peripheral pulses on both sides. The axillary nerve (regimental) must be evaluated Posterior: • Arm held in adduction and internal rotation • Anterior shoulder is squared off, flat with the prominent coracoid process when viewed from above • Neurovascular deficits infrequent • Patient resists external rotation Inferior: • Arm fully abducted with elbow commonly flexed or behind the head • Humeral head may be palpable on the lateral chest wall • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately continued … 51 Identifier Read Code Differential Diagnosis Dislocation/Subluxation Shoulder continued S41.. continued • AC injury • R/C tear • Fractures of the humerus Investigation X-rays: • AP joint space (glenoid fossa view), transcapular lateral or axillary view, AP internal rotation shoulder girdle • Posterior dislocations are often missed, so careful examination of the appropriate X-rays is important Action Plan • Monitor vital signs regularly i.e. 15 minute intervals, following controlled drug use with attention to respiratory rate and adverse effects • X-ray prior to reduction • Discuss and refer to a medical practitioner for reduction • Successful reduction is evidenced by a palpable or audible relocation, marked reduction in pain and increased range of motion • 1st dislocation, broad arm sling 3-6 weeks with orthopaedic review if aged >40 years or complication present • If the dislocation is recurrent, sling and rest until comfortable. Specialist review for all. Start physiotherapy and mobilise at 1 week • Check dislocations in elderly patients at 1 week for R/C injury • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Post reduction: • Post-reduction X-ray should be done • Axillary nerve status assessed and documented by medical practitioner • In the elderly, mobilisation should be started at 1 week to reduce the occurrence of stiffness • Pain medication plan based on prescription Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Refer to GP or ED to exclude complications, neurovascular compromise, suspected fracture, irreducible dislocation • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy at approximately 4 weeks to ensure shoulder mobility, especially in the elderly • In children: suspected nerve paralysis requires early multidisciplinary intervention continued … 52 Identifier Read Code Patient Education Dislocation/Subluxation Shoulder continued S41.. continued • Education on use of the sling and explain the shoulder should be immobilised for up to 4 weeks • Educate how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome, and seek immediate medical attention • Report any swelling or change in sensation • Explain pain medications – keeping up with regular paracetamol, or NSAIDs as recommended by medical practitioner • Instruct on maintaining mobility of fingers and unaffected joints • Advise limitations of exercise and the importance of not putting any weight on the affected arm • Advise rest • Avoid HARMS • Arrange appropriate follow-up • Physiotherapy – aggressive rehabilitation recommended for 1st-time dislocations: importance of preventing recurrent dislocation by correct management of the injury; no contact sport for 6 weeks (or longer as directed by physiotherapist) 53 Dislocation Subluxation Finger/Thumb Identifier Read Code Key Points 54 Dislocation Subluxation Finger/Thumb S44.. • Typically associated with forced hyperextension or hyperflexion of the digit and requires immediate reduction • Hand dominance may affect management Complications • Late or delayed reduction may result in loss of joint motion, joint instability and limitation of hand function • Gamekeeper’s thumb – if unrecognised and untreated, may lead to progressive MP subluxation with interference with the grasp, causing significant disability History • Comprehensive nursing assessment • Mechanism of injury: jammed or bent backwards during sport is typical • Identify the patient’s dominant hand Assessment (According to Competency) Differential Diagnosis • Refer to medical practitioner for 2-phase test for functional stability done under digital or wrist block • Record objective signs of neurovascular status Investigation X-rays: • AP, lateral, oblique • Always X-ray even where the dislocation has been reduced Action Plan • Remove rings • Complete pain assessment and provide adequate pain relief by standing orders or prescription • If stable, consider mobilisation after pain and swelling have settled (3-5 days) • If unstable, refer for specialist management • Monitor neurovascular status • Elevate limb to control swelling Refer for reduction to a medical practitioner • Consider options of traction reduction: – without anaesthesia; or – with anaesthesia – digital nerve block 10-15 minutes prior to reduction (according to competency) • Following the reduction – check for concentric reduction – do not accept anything less than perfect • Should have normal range of motion • Note that some dislocations will require open reduction, therefore do not try excessively Dorsal: • Immobilise in Zimmer splint in 30° flexion for 3-4 days, then: – Mobilise strapped to the adjacent digit for 2-3 weeks or leave free – Additional strapping during sport for a further 3 weeks • If not stable it may indicate need for repair of the collateral ligament Volar: • Apply the splint only to the DIP joint on the volar aspect; the DIP joint should be in full extension Chronic instability: • Assess clinically and refer to specialist for repair and reconstruction • Dislocations, hand • Fractures, hand • Hand injuries, soft tissue • Gamekeeper’s thumb (skier’s thumb) continued … Identifier Read Code Onward Referral Patient Education Dislocation Subluxation Finger/Thumb continued S44.. continued • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Refer to GP or ED to exclude complications such as suspected open dislocation, neurovascular compromise, ligament rupture, joint instability, associated fracture • Nerve lesions require specialist physiotherapy, orthopaedic follow-up and social rehabilitation assessment • The patient, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy or hand clinic if hand function is limited • Teach and explain how to self-assess for signs of circulatory or nerve compression, or the development of compartment syndrome or infection, and seek immediate medical attention. If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Explain pain medications – keeping up with regular paracetamol, avoiding all NSAIDs • Teach about care of splint and use of sling • Instruct on maintaining mobility of other fingers and unaffected joints • Advise limitations of exercise • Advise rest and elevation • Avoid HARMS • Arrange appropriate follow-up 55 56 Section Two: Burns Overview.........................................................................................................................................................59 Key Points for Management..........................................................................................................................59 Burn Depth Assessment...............................................................................................................................60 Codes and injuries SHO.. Burn Eye and Adnexa...........................................................................................................65 SH1.. Burn Face, Head, Neck.........................................................................................................67 SH2../SH3../SH5.. Burn Trunk/Arm (Excluding Wrist, Hand)/Lower Limbs..........................................................69 SH4.. Burn Wrist and Hand............................................................................................................71 57 58 Burns Overview Key Points for Management Resuscitation • Airway, breathing, circulation, neurological state (if reduced level of consciousness or confusion, suspect carbon monoxide exposure and give high flow oxygen) • Assessment for potential airway compromise • Assess and treat or refer as appropriate • Guideline for urgent referral for medical advice or admission: – Superficial burns >15% body surface area in a child or elderly person, >20% in an adult – Deep or full-thickness burns – Burns of the face, neck, hands, feet and genital area regardless of the total body area affected – If airway or pulmonary injury is suspected – Management or social circumstances (consider abuse) – Infected burns (treat as prescribed or using standing orders) – Electrical burns – Electrical burns in pregnancy – Chemical burns – Burns to the eye – Alkali burns to the eye are ocular emergencies – Circumferential burns – Burns at the extremes of age – Complicated pre-existing medical conditions. Tetanus Prevention There is a risk of tetanus following a burn injury. Refer to the guidelines on the prevention of tetanus following injury, which are available from the Ministry of Health’s Immunisation Handbook 2006. Non-accidental Injury from Burns and Scalds Indicators of possible non-accidental burns or scalds include the following: • • • • • • • • • • Delay in seeking help Historical accounts of injury differ over time History inconsistent with the injury presented or with developmental capacity of child Past abuse or family violence Inappropriate behaviour/interaction of child or caregivers Glove and sock pattern scalds Scalds with clear-cut immersion lines Symmetrical burns of uniform depth Restraint injuries on upper limbs Other signs of physical abuse or neglect. Refer to a regional burns unit if non-accidental injury is suspected. 59 Burn Depth Assessment The depth of a burn injury should be reassessed, preferably by the same clinician, 2-3 days after the initial assessment. 60 depth colour blisters capillary refill sensation healing Superficial/Erythema Red No Present Present Yes Superficial partial thickness Pale pink Small Present Painful Yes 7-10 days Deep partial thickness Blotchy red Larger absent Absent Absent Prolonged Full thickness White No Absent Absent No Complications • Infection • Scarring • Contractures • Toxic shock – up to 7 days after burn • Internal organ damage (inhalation, shock, direct injury) • Psychological distress History • Comprehensive nursing assessment • Time and duration of exposure • Nature of exposure • First aid measures administered • Fire in contained space, exposure to fumes, smoke or gases • Drug or ethanol intoxication Assessment (According to Competency) • Location • Body surface area • Depth • Singeing of nasal hair • Carbonaceous sputum (discoloured sputum from smoke inhalation) • Dysphonia/Hoarseness • Stridor • Intraoral/Pharyngeal burns • Respiratory distress • Identify other significant injuries Action Plan • Acute • Monitor airway, breathing, circulation • Cooling: – 20 minutes under running tap water (at 8-15°C) OR saline/watersoaked dressings – Cooling has no effect after 3 hours post burns and should not be started if this time has elapsed when the patient is first seen – Avoid ice (may exacerbate tissue injury) – Be aware of potential for hypothermia, especially in children with large burns • Refer to tertiary service/hospital under guideline for admission above • Complete pain assessment and provide adequate pain relief by standing orders or prescription: – Oral or IV (aliquots of morphine) – if possible avoid IM/subcutaneous routes (erratic absorption and slower onset of action) OR inhaled e.g. nitrous oxide. Refer to medical practitioner if analgesia to be administered IV continued … Action Plan continued • Elevation – If oedema is expected in limbs, elevate the area to improve venous return • Release constricting clothing and jewellery before oedema formation • Fluid balance: – Full-thickness burns or superficial burns greater than 15% BSA may be associated with fluid displacement. Monitor urine output, pulse and BP. IV fluids may be indicated, refer to medical practitioner • Dressings: – Wash area gently with warm normal saline Dressing products: (From The Management of Burns and Scalds in Primary Care 2007) International evidence is lacking around the use of dressing products in primary care. Silver sulphadiazine is understood to be widely used at present on burns in primary care. This practice is supported by the expert opinion of the Guideline Development Team for its properties as an anti-infective agent. However, extended use of silver sulphadiazine on a non-infected wound has been shown to have adverse effects on the time to healing in burns wounds. Expert opinion strongly favours the use of moist wound healing products for superficial and mid-dermal burns, although the evidence is scanty and inconsistent. There is no convincing evidence from primary randomised controlled studies that any other dressing product heals wounds significantly faster than paraffin gauze (which is considered a non-moist dressing) • Superficial: – No treatment other than a dressing product to maintain a moist healing environment e.g. a hydrogel and/or retentive dressing OR film dressing – Normal hygiene can be maintained and the exudates washed off with tap water on town supply or normal saline and carefully dried twice a day. This can be left in place and maintained for up to 7-14 days providing this wound care is manageable for the patient. Reassess as necessary. As wound re-epithelialises the dressing will detach from the skin; trim as necessary. The area should be covered with vegetable oil 2-3 hours prior to the removal of the retentive dressing • Partial thickness: – There are many commercial dressings available for use on these burns and selection is controversial. The following represents a number of approaches in current use: 1.Calcium alginate or a hydro fibre (e.g. Aquacel) covered by a retentive dressing to allow evaporation of excess fluid. Initially a dry dressing pad may be placed over the retentive dressing for protection. Patients require written instructions on care that explain the importance of observing for signs of infection. The dressing must be kept dry at all times, cover during showering – do not soak in water e.g. bathing, dish/clothes washing. This can be left in place and maintained for up to 7-14 days providing that it is manageable for the patient and it supports healing. Reassess as necessary. A moist interface is maintained but as the excess fluid evaporates a scab-like crust is formed under the retentive dressing. As the wound re-epithelialises the dressing will detach from the skin; trim as necessary. The area should be covered with a clean polyunsaturated oil 2-3 hours before removal. continued … 61 Action Plan continued 2.Low-adherent impregnated dressing with overlying absorbent dressing: – Change of absorbent layer at 48 hours – Remove absorbent dressing and reassess wound – Reapply if necessary – Reassess earlier if signs of infection e.g. local heat, increasing tenderness, inflammation, offensive discharge, swelling, systemic illness, fever – The dressing must be kept dry at all times, cover during showering – do not soak in water e.g. bathing, dish/clothes washing – Patients require written instructions on care that explain the importance of observing for signs of infection 3.Silver sulphadiazine applied to burn and covered with absorbent dressing: – Reapply if necessary – After 3 days tulle gras dressing or calcium alginate or hydro gel covered by a retentive dressing unless concerns i.e. infection 4.Hydrocolloid dressing: – Change every 3-5 days, earlier if signs of infection • Blister management: – If burst: carefully debride and remove any remaining blister fluid. This fluid has been shown to be detrimental to wound healing – Blisters should be debrided and the blister fluid removed except for blisters on the soles and palms • Full-thickness burns: – As advised by a medical practitioner/specialist. These patients may be suitable for immediate skin grafting – Cling film is a useful cover for transportation to hospital/do not wrap around limbs or torso, rather lay it on longitudinally to prevent circulation constriction associated with swelling and fluid loss • Tetanus toxoid immunisation If required (see Overview: Other Soft Tissue Injuries: Antibiotic Prophylaxis and Tetanus Prophylaxis) • Monitoring: Monitor the burn site (signs of infection and tissue check), make arrangements for dressing changes. Note toxic shock (secondary to superficial staph infection)may affect patients with burns with less than 2% BSA Chemical Burns 62 • Majority are acids and alkalis • Injury may occur as a result of direct tissue burn and/or toxicity from systemic absorption • Management focuses on decontamination, antidotes where appropriate and treatment of systemic toxicity • Initially brush off dry chemical particles then copious irrigation with running water or saline • Duration of irrigation dependent on agent. Alkalis may require prolonged irrigation, especially the eye • pH testing with litmus paper can be used to guide duration of irrigation • Metal fragments embedded in skin should be covered with mineral oil or sand not water • Seek immediate medical/specialist advice regarding management of chemical burns, especially exposure to hydrofluoric acid, metals or alkalis • Hydrofluoric acid burns: individuals should have calcium gluconate gel prescribed, or applied under standing orders, to the area (if available) prior to transfer to hospital (made by mixing KY jelly with calcium gluconate to make a 2.5-10% solution) continued … Electrical Burns (See Miscellaneous: Read Code: TL01. Electrical Injury) • May be superficial – full thickness • Deeper structures, particularly nerves and blood vessels, may be severely damaged • Ensure full assessment (may require referral to medical practitioner) to exclude other injuries • Ongoing management of individuals with electrical burns (unless trivial) should be discussed immediately with medical practitioner/specialist • Pregnant women suffering an electrical injury should be referred urgently to medical practitioner for transfer to hospital for foetal assessment • Individuals exposed to low-voltage electricy (i.e. domestic supply) should have an ECG performed and discussed with medical practitioner – If normal – cardiac monitoring is not necessary unless known ischaemic heart disease – If abnormal – patient should be transferred immediately to hospital by ambulance for assessment • Individuals exposed to high-voltage electricity should be discussed with medical practitioner and transferred to hospital by ambulance for immediate assessment Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Consider onward referral to the GP, ED, physiotherapy, occupational therapy, social rehabilitation assessment • Early referral for pain management and psychological services may be appropriate • Post injury, scarring, contractures and nerve lesions require specialist physiotherapy, plastic surgery follow-up and social rehabilitation assessment • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy if scarring has potential to affect range of movement Patient Education • Advise patient to return if any signs or symptoms of infection or toxic shock e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • For uncomplicated superficial burns – simple analgesia as required e.g. paracetamol • Educate about how to keep dressing/burn dry • Instruct on how to manage daily personal hygiene i.e. showering/ bathing • Instruct patient to return promptly if any discharge strikes through bandage or dressing • Instruct patient to return promptly if blister formation affects any joint movement • Rest as much as possible until burn healed • Elevate limbs if there is swelling or a risk of oedema formation • Return for regular dressings where applicable • Watch for delayed haemorrhage in perioral burns in children • Advise patient of common expected side effects after a tetanus immunisation continued … 63 Patient Education continued Teach patient accident prevention and first aid treatment for burns • Do not put anything other than cool water on a burn • 20 minutes under running tap water (at 8-15°C) or saline/water-soaked dressings or hold the burn submerged in a deep receptacle of water or a pool • Cooling has no effect after 3 hours post burns and should not be started if this time has elapsed when the patient is first seen • Avoid ice (may exacerbate tissue injury) • Keep hot water between 50° and 55° at the tap. Ask a local energy supplier or a plumber for advice on how to adjust it, if necessary • Keep a multi-purpose fire extinguisher handy and check it annually • Install smoke detectors – check they work. Replace the batteries annually e.g. the start of daylight saving Accident prevention with pre-schoolers • Always run cold water first when running a bath to prevent scalds • Always supervise children in the bath • Hook electrical cords out of the way so small children cannot reach them or pull on them • Refill the electric jug with cold water after use • Use childproof tap covers (caps) on hot water taps • Never hold a hot drink while nursing a baby or holding a child • Keep hot drinks out of reach of children • Choose safe nightwear • Use placemats on the table, not a tablecloth • Use the back elements on the stove with pot handles turned inwards • Secure stove to the wall so it cannot be tipped up if child stands on opened door • Put matches and lighters away safely 64 Burn Eye and Adnexa Identifier Read Code Key Points Burn Eye and Adnexa SHO.. • Ocular burns: – Potentially blinding – Commonly caused by contact with chemicals or over-exposure to UV light (welding, sun-beds) • Chemical burns: – Alkali burns (bleach, chemical detergents, plaster/concrete) are true ocular emergencies – All chemical burns should be managed initially by copious irrigation – Cycloplegic agents, applied under prescription or standing orders, provide considerable pain relief in UV keratitis • Thermal burns: – Commonly affect the lids because of the protective blink reflex – Rarely affect the eyes – Silver sulphadiazine should not be used on the eyelids in thermal burns – Only saline or prescribed ophthalmic products should be used on or near the eyes Complications • Thermal: – Scarring – Contractures • Chemical: – Perforation of globe – Corneal scarring – Adhesion of lids to globe – Glaucoma – Cataracts – Retinal damage History • Comprehensive nursing assessment • Nature of exposure • Time and duration of exposure • First aid administered Assessment (According to Competency) • Initial focus on airway, breathing, circulation and neurological state as appropriate • After irrigation (or cooling of thermal burns): – Assess visual acuity – Assess nature, depth, area of burn – Refer to medical practitioner for ophthalmoscopy with fluorescein to assess corneal epithelial damage Differential Diagnosis Investigation • Other causes of keratitis for UV burns • Nil appropriate if isolated eye/adnexal burn continued … 65 Identifier Read Code Action Plan 66 Burn Eye and Adnexa continued SHO.. continued • Tetanus – see Wound Management Overview Chemical burns: • Apply topical anaesthetic as prescribed or under standing orders. Then irrigate with saline warmed to approximately 8-15°C through an IV giving set for 15-20 minutess. Tap water at 8-15°C if saline is not immediately available. Check fornices/double evert upper lid to detect and remove particulate matter with moist cotton bud • Continue irrigation until pH of tear film is 7.0-7.4. Recheck pH after 10 minutes • Urgent referral of all alkali burns: – If uncertain about pH in alkali burn, continue irrigation throughout transfer to hospital • Non-alkali burns – after irrigation – refer to medical practitioner for staining with fluorescein to assess damage to corneal epithelium • Apply chlormycetin ointment by prescription or standing orders and double pad eye • Complete pain assessment and provide adequate pain relief by standing orders or prescription Thermal burns of lids: • Superficial (no blistering): apply antibiotic ointment by prescription or standing orders e.g. Chloramphenicol based • Partial thickness/full thickness: as above and referral • Appropriate analgesia by prescription or standing orders UV burns: • Topical antibiotic • Cycloplegic agent – Cyclopentolate 1% TDS • Analgesia Above treatments by prescription or standing orders Reassess all burns at 24 hours Note: Driving is not permitted with a padded eye Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • All burns to the eye and adnexa should be discussed with a medical practitioner: – Chemical burns: may require urgent referral to ophthalmologist for an alkali burn or if evidence of corneal damage – Thermal burns: partial/full thickness – will be referred to ophthalmologist or plastic surgeon – UV keratitis: will be referred to ophthalmologist if not settled within 48 hours • Early referral for pain management and psychological services may be appropriate • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Children may require a specialist rehabilitation assessment (for educational needs) Patient Education • Educate about the importance of keeping the eye covered, regular applications of topical ATBs and the importance of returning for assessment at 24 hours • Explain pain medications – keeping up with regular paracetamol or NSAIDs as recommended by the medical practitioner • Advise rest to reduce oedema around the eye • Arrange appropriate follow-up • Children may require specialist rehabilitation assessment Burn Face, Head, Neck Identifier Read Code Key Points Burn Face, Head, Neck SH1.. • Airway, breathing and circulation • Patients with history/examination findings suggestive of inhalation injury should be transferred to hospital urgently • Adequate cooling for all burns – 20 minutes under running water at 8-15°C or saline/water-soaked dressings • Oral and perioral burns are the most common electrical injury in children and result from chewing on a live cable. An apparently trivial burn may later cause severe haemorrhage from the labial artery Complications • Airway compromise • Respiratory embarrassment • Scarring/Contractures • Perioral electrical burns: – Delayed haemorrhage – Scarring – Impaired jaw growth – Abnormal speech development • Infection History • Comprehensive nursing assessment • Nature of exposure • Risk factors for inhalation injury • Time and duration of exposure • First aid administered Assessment (According to Competency) • Initial focus on airway, breathing, circulation and neurological state as appropriate • Signs suggestive of inhalation injury: – Oral/Pharyngeal burns – Stridor/Hoarseness/dysphonia – Respiratory distress – may occur 2-3 hours after initial injury. A respiratory rate above 20 should alert the clinician to potential breathing problems – Carbonaceous sputum – Singed nasal hair – Reduced level of consciousness • After cooling assess nature, depth and area of burn • Assess and record visual acuity if eyes involved Investigation • Nil initially if isolated thermal burn to face, head or neck • Burn swab and culture may be required later if infection develops • Electrical burn – see Burns Overview • For suspected fluid loss: bloods – FBC, glucose, U+E, CoHb: ECG • CXR – for suspected inhalation • Burn swab and culture may be required later if infection develops continued … 67 Identifier Read Code Action Plan 68 Burn Face, Head, Neck continued SH1.. continued • Resuscitation as necessary • Rapid cooling for 20 minutes by tap water at 8-15°C or warmed saline • Analgesia as appropriate, by prescription or standing orders • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Tetanus – see Wound Management Overview • Superficial (erythema only) – see Burns Overview • Superficial partial thickness (small blisters only): Discuss management/ need for further referral with medical practitioner – Blister management – see Burns Overview Face: – Do not use silver sulphadiazine on the face – Hydrating product liquid paraffin 2-4 hourly to keep moist – Eyelids – Chlormycetin ointment by prescription or standing orders – Ears – Chlormycetin ointment by prescription or standing orders – Lips – soft white petroleum jelly as required to keep moist – Neck – see Burns Overview • Deep partial thickness (larger blisters)/full thickness: refer to medical practitioner for discussion with plastic surgeon or specialist according to local protocols • In discussion with medical practitioner, consider insertion of nasogastric tube if risk of swelling Onward Referral • Refer urgently to ED, hospital actual or potential inhalation injury partialor full-thickness burns to face or ears • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Early referral for pain management, psychological services or speech and language therapy may be appropriate • Early scar management requires specialist plastic surgery and follow-up • Scarring in the neck or jaw area may require specialist physiotherapy • Scarring of the scalp may result in permanent hair loss – discuss referral for wig with medical practitioner • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Children may require a specialist rehabilitation assessment (for educational needs) Patient Education • Advise patient to return if any signs or symptoms of discharge, infection or toxic shock e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • Educate on the importance of keeping the area of the burn covered, and the importance of returning for regular dressings • Explain pain medications – keeping up with regular paracetamol or NSAIDs as recommended by the medical practitioner • Instruct how to manage daily personal hygiene i.e. showering/bathing • Advise rest to help healing • Arrange appropriate follow-up Burn Trunk/Arm (Excluding Wrist, Hand)/Lower Limbs Identifier Read Codes Key Points Burn Trunk/Arm (Excluding Wrist, Hand)/Lower Limbs SH2../SH3../SH5.. • Monitoring of airway, breathing and circulation • Adequate cooling: 20 minutes under running tap water at 8-15° or saline/water-soaked dressings • Analgesia as appropriate by prescription or standing orders • Assessment of burn, documenting area involved, depth and location Complications • Shock (requirement for IV fluid therapy if body surfaces are burnt >20% in adult or >15% in child or elderly, or clinical signs of shock) • Add daily maintenance fluids to fluid regimen • Hypoglycaemia in children • Hypothermia (care with cooling large area involved and/or child) • Infection • Scarring/Contractures History • Comprehensive nursing assessment • Nature of exposure: – Flame – Chemical – Hot fluid – Superheated gas – Electrical • First aid administered • Time and duration of exposure • Contamination of burn Assessment (According to Competency) • Initial focus on airway, breathing, circulation and neurological state • Assess area, depth, location of burn • Note circumferential burns • Check neurovascular status of limb • Examine for injury to deeper structures Investigation • Bloods – FBC, glucose, U+E, CoHb • ECG • CXR – refer for X-ray and reporting as appropriate • Burn swab and culture may be required later if infection develops • Electrical burn – see Burns Overview Action Plan • Resuscitation as necessary • Rapid cooling for 20 minutes • Refer urgently as per guideline protocol above • Monitor pulse, BP, respirations and urine output • Remove jewellery where applicable • Complete pain assessment and provide adequate pain relief by prescription or standing orders • Dressings – see Burns Overview • Advise elevation of limb burns • Genitalia/Perineum – may require catheterisation Follow-up treatment: • Dressing changes as per overview • Follow-up pain assessment • Screen for psychological distress • Monitor for infection and toxic shock continued … 69 Identifier Read Codes Onward Referral Patient Education 70 Burn Trunk/Arm (Excluding Wrist, Hand)/Lower Limbs continued SH2../SH3../SH5.. continued Urgently to hospital: • Actual or potential inhalation injury, refer urgently for admission to local ED • Burns associated with other serious injuries • Partial-thickness burns: – >15% BSA all ages – >10% BSA <10 or >50 years • Smaller burns if significant co-morbidities • Possibility of non-accidental injury in children • Full thickness burns • Burns involving feet (unless trivial), genitalia, perineum • Any heavily contaminated burn • Persisting requirement for IV analgesia after dressing completed • Electrical burns • Difficult social and management issues e.g. young children requiring sedation for dressing changes and ongoing management may require admission Other referral: • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Early referral for pain management and psychological services may be appropriate • Partial-thickness burns – discuss management with medical practitioner as some areas may need skin grafting • Post injury – scarring, contractures and nerve lesions require specialist plastic surgery follow-up and social rehabilitation assessment • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy if scarring has potential to affect range of movement • Advise patient to return if any signs or symptoms of infection or toxic shock e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • For uncomplicated superficial burns – simple analgesia as required e.g. paracetamol • Educate how to keep dressing/burn dry • Instruct how to manage daily personal hygiene i.e. showering/bathing • Instruct patient to return promptly if any discharge strikes through bandage or dressing • Return promptly if blister formation affects any joint movement • Rest as much as possible until burn healed • Elevate limbs if there is swelling or a risk of oedema formation • Return for regular dressings where applicable • Advise patient of common expected side effects after a tetanus immunisation Burn Wrist and Hand Identifier Read Code Key Points Burn Wrist and Hand SH4.. • Airway, breathing and circulation • Adequate cooling: 20 minutes under running tap water at 8-15°C, longer if alkali chemical burn • Analgesia as appropriate on prescription or standing orders • Assessment of burn. Emphasis on nature of exposure, depth and impairment of hand function Complications • Scarring/Contractures • Loss of function History • Comprehensive nursing assessment • Nature of exposure: – Flame – Chemical (particularly hydrofluoric acid) – Hot fluid – Superheated gas – Electrical • Time and duration of exposure • First aid administered • Contamination of burn Assessment (According to Competency) • Initial focus on airway, breathing, circulation and neurological state as appropriate • Assess area, depth of burn • Note circumferential burns • Identify entry/exit burns in electrical injuries • Identify injury to deeper structures, particularly neurovascular status in electrical burns • Note blister formation around joints Investigation • Electrical burns – ECG • Extensive burns with risk of fluid displacement: bloods Action Plan • Resuscitation as necessary • Rapid cooling for 20 minutes • Complete pain assessment and provide adequate pain relief by prescription or standing orders • Monitor pulse, BP, neurovascular status and urine output • Remove jewellery • Dressings – see Burns Overview – Ensure hand is elevated in a high-elevation sling to minimise dependent oedema – Hydrofluoric acid burns – see Burns Overview continued … 71 Identifier Read Codes Onward Referral Burn Wrist and Hand continued SH4.. continued • Immediate referral for tertiary assessment at hospital (as per urgent referral guideline): – Full-thickness burns – Circumferential burns – Burns with restriction of joint function due to pain or depth of burn – Electrical burns – Hydrofluoric acid burns – see Burns Overview Other referral • Refer for medical reassessment suspected infection, delayed healing, partial-thickness burns • Early referral for pain management and psychological services may be appropriate • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Post injury, scarring, contractures and nerve lesions require specialist plastic surgery follow-up • Patients, especially the elderly living alone, may require assessment of ADLS and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy or hand clinic if scarring has potential to affect range of movement Patient Education 72 • Elevate limb – instruct on use of sling • For uncomplicated superficial burns – simple analgesia as required e.g. paracetamol • Educate how to keep dressing/burn dry • Instruct how to manage daily personal hygiene i.e. showering/bathing • Instruct patient to return promptly if any discharge strikes through bandage or dressing • Return promptly if blister formation affects any joint movement • Rest as much as possible until burn healed • Follow-up management – regular dressings where applicable • Advise patient to return if any signs or symptoms of infection or toxic shock e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • Advise patient of common expected side effects after a tetanus immunisation Section Three: Gradual Onset Codes and injuries F340. Carpal Tunnel Syndrome.......................................................................................................74 N211. Rotator Cuff Syndrome.........................................................................................................76 N2131/N2132 Medial and Lateral Epicondylitis – Elbow.............................................................................78 N2165 Prepatellar Bursitis...............................................................................................................81 N2174/S5504 Achilles Tendonitis/Sprain Achilles Tendon..........................................................................82 N220. Synovitis/Tenosynovitis.......................................................................................................84 73 Carpal Tunnel Syndrome Identifier Read Code Key Points Carpal Tunnel Syndrome F340. • Symptomatic median nerve neuropathy • Important to identify cause and therefore consider associated conditions such as (hypothyroidism) pregnancy, rheumatoid arthritis, diabetes, gout, high BMI or recent weight gain • Management includes compression at the wrist Complications • Chronic pain • Paraesthesia (loss of sensation) • Muscle wasting • Occupational/Functional problems (may require modified duties) History • Comprehensive nursing assessment • Nature of the pain – night pain or tingling in the hand, may radiate to forearm and arm, pain aggravated by excessive, prolonged or repetitive movements/activity • Loss of sensation in median nerve distribution • Insidious onset • Weakness of grip (due to weakness of thumb) • Cervical spine symptoms and other medical conditions e.g. thyroid disease, pregnancy, diabetes, weight gain, renal disease • Occupation – this may be a contributing factor but may not be the cause • History of previous fracture/trauma to wrist Assessment (According to Competency) • Sensory changes in median nerve distribution (first 3 digits) • Muscle wasting of short abductor muscle of thumb (thenar wasting) • Muscle strength – weakness thumb abduction • Cervical spine Differential Diagnosis • Cervical spine dysfunction • Thoracic outlet syndrome • Connective tissue disorders • Other forearm nerve compression • Tendonitis wrist and elbow • Arthritis • Chronic pain • Other forms of neuropathy Investigation In consultation with medical practitioner: • Nerve conduction studies can demonstrate slowing of the median nerve relative to other nerves in the hand and support the diagnosis • Blood tests – for thyroid function, uric acid, glucose, rheumatology screen and FBC continued … 74 Identifier Read Code Action Plan Onward Referral Carpal Tunnel Syndrome continued F340. continued Initial treatment: • Identify and modify precipitating factors • Workplace assessment – modification of work tasks • Take regular breaks from repetitive tasks, especially activities in cold environments • Avoid prolonged flexion of the wrists and direct pressure over the base of the hand • Patient education • Wrist splint (especially at night) • Use of anti-inflammatory gels • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Follow-up treatment post surgery: • Patient education: signs of infection, elevation, keep wound dry for 72 hours, time off work: light tasks – 2 weeks, heavy work – 6 weeks • Monitor and manage pain • Refer back to medical practitioner if symptoms are not settling • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Patients with associated grip weakness and sleep disturbance should be referred to the medical practitioner who may consider pain medication and trial of steroid injection and review indications for surgery • Referral to physiotherapy to maintain range of movement of adjacent joints, patient education • Patients, especially the elderly living alone, may require assessment of ADLS and IADLS via social rehabilitation assessment 75 Rotator Cuff Syndrome Identifier Read Code Key Points 76 Rotator Cuff Syndrome N211. • Defined as shoulder pain associated with any of the following: – Overuse – Repetitive movement – Following a poorly rehabilitated acute injury – Movement associated with biomechanical or anatomical abnormalities • Progressive pathological process • Pain is the most common symptom in all gradual onset injuries • May be caused by, or lead to tendonitis • R/C tendonitis and sub-acromial bursitis both present with impingement or painful arc syndrome • Impingement occurs when the space between the underside of the acromion and the top of the glenohumeral joint effectively narrows due to any or combinations of the following: – Osteophytes from above – Inflamed subacromial bursa – Inflamed/Swollen R/C – Excessive elevation of the humeral head • Impingement classically occurs between 60° and 120° • Instability usually occurs following an acute injury to the shoulder causing a dislocation or subluxation. The ball and socket joint becomes unstable and displays excessive movement. This can also lead to irritation and inflammation of the surrounding structures, resulting in impingement • Age considerations – tendon degeneration from gradual onset damage to the R/C is age related: – Oedema and haemorrhage, age <25 years – Fibrosis and tendonitis, age 25-40 years – Tears of cuff, age >50 years Complications • Subscapularis or biceps tendon rupture • Chronic pain and shoulder dysfunction • Failure of conservative treatment will require surgical intervention • Decreased range of motion • Frozen shoulder History • Comprehensive nursing assessment • Age • Site, duration, severity of pain • Night pain • Shoulder positions that either exacerbate or alleviate pain • History of acute injury/strenuous or repetitive activity, especially overhead • Chronic osteoarthritis of GH or AC joint Assessment (According to Competency) • Compare shoulders for muscle wasting/strength • Local tenderness • Crepitus, swelling • Range of movement • Passive movement/painful arc • Resisted movements continued … Identifier Read Code Differential Diagnosis Rotator Cuff Syndrome continued N211. continued • Arthritis of AC and GH joints • Calcific tendonitis • Traumatic anterior subluxation of humerus • Traumatic R/C tear or rupture • Subscapularis or biceps tear/rupture • Instability • Avascular necrosis of humeral head • Capsulitis Investigation • In consultation with medical practitioner: – X-ray – Ultrasound Action Plan In consultation with medical practitioner: • Rest initially • Maintain range of movement with physiotherapist • NSAIDs • Activity modification • Identify causative factors and advise patient of behaviour changes needed • Refer on to medical practitioner early • Steroid injection – usually into subacromial space (medical practitioner) • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer accordingly Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Refer to medical practitioner for investigation and diagnosis, especially where there are any neurological features, suspicion of arthritis or tendon rupture. Patient may require a specialist orthopaedic consultation • Patients, especially the elderly living alone, may require assessment of ADLS and IADLS via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy, acupuncture, for treatment • Refer to occupational health nurse or occupational therapist for work site assessment if appropriate 77 Medial and Lateral Epicondylitis – Elbow Identifier Read Codes Key Points Medial and Lateral Epicondylitis – Elbow N2131/N2132 • The name suggests inflammation but the condition is usually a degenerative condition of the common tendon attachment at either the medial or lateral epicondyle • Common presentation associated with manual workers performing repetitive forceful tasks, some connective tissue disorders and age (peaks in the 4th and 5th decades) • Check work tasks and hobbies – may be contributory rather than causative • For medial epicondylitis (golfer’s elbow), pain is associated with excessive activity of the wrist flexors and pronation/supination of wrist • For lateral epicondylitis (tennis elbow), the pain is associated with excessive activity with pronation/supination and extension of wrist • Combination of force and repetition Complications • Atrophy from steroid injections • Complex regional pain syndrome • Chronic functional loss History • Comprehensive nursing assessment • Pain: – Usually diffuse – occasionally more localised, may be severe – Onset acute or insidious – Recent changes in tasks at work or leisure – Blow to elbow – Pain may be aggravated by simple tasks or by repetitive activities – If pain is related to activity, it is more likely to be mechanical in origin whereas if pain is persistent and unpredictable it may be referred pain and/or related to posture • Past injury • Other upper limb symptoms – particularly numbness, tingling or weakness which may suggest alternative diagnosis • Check work activities, hobbies and sports: ask about specific task changes in work processes, and hobbies Assessment (According to Competency) • Include observation/active movements/passive movements/resisted movements/palpation • Note local tenderness or crepitus (tendon) • Note pain with stressing/stretching wrist/extensors or flexors • Examine cervicothoracic spine • Examine wrist, hand and shoulder joints as appropriate • Neurovascular status especially the radial, ulnar and median nerve continued … 78 Identifier Read Codes Differential Diagnosis Medial and Lateral Epicondylitis – Elbow continued N2131/N2132 continued Lateral elbow pain: • Extensor tendinosis • Referred pain – from cervical spine, upper thoracic spine • Synovitis of the radiohumeral joint • Radiohumeral bursitis • Radial tunnel syndrome • Intersection syndrome Medial elbow pain: • Flexor/pronator tendinosis • MCL sprain • Ulnar nerve compression • Avulsion fracture of the medial epicondyle • Apophysitis • Referred pain neck or shoulder pathology • Tendon rupture – biceps • Arthritis (septic arthritis, osteoarthritis, connective tissue disorder) • Forearm muscle strain Investigation In consultation with medical practitioner: • Ultrasound or X-ray if indicated • Blood tests if systemic or arthritic conditions suspected • Nerve conduction studies or diagnostic nerve block if indicated Action Plan • The aims of treatment are to eliminate pain, identify and change the causative factors and normalise function with conservative treatment initially • Identify and remove/reduce stressors, modify work and non-work activity to selectively rest the forearm • Graduated return to activity – occupational health nurse support for modified work • Narrow tennis elbow band all day – ensure patient knows how to put it on • Advice on prescribed and over-the-counter medications: antiinflammatory gel • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess the level of independence and refer appropriately Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Refer to medical practitioner for investigation and diagnosis, especially where there are any neurological features, suspicion of arthritis or tendon rupture. Patient may require a specialist orthopaedic consultation • Patients, especially the elderly living alone, may require assessment of ADLS and IADLS via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy, acupuncture, occupational health nurse or occupational therapist Patient Education • Advice and education on how to avoid precipitating factors • Warm up before doing exercises that involve elbow or arm muscles • Rotate work so that not working for extended periods using same muscles repetitively (employer may need support to enable suitable tasks to be incorporated into daily work) • Advice on pain medication and use of splint or band continued … 79 Identifier Read Codes Follow-Up Action Plan 80 Medial and Lateral Epicondylitis – Elbow continued N2131/N2132 continued • Patients who progress to surgery: – Rest and wound care for 2-3 weeks – Gradual increase in activity in liaison with orthopaedic surgeon – Gradual resumption of work tasks when cleared by orthopaedic surgeon • At review: – Monitor and manage pain – Reassess neurological symptoms – Reassess functional grip – Refer to medical practitioner as appropriate Prepatellar Bursitis Identifier Read Code Key Points Prepatellar Bursitis N2165 • If occupation involves kneeling or knee pressure, treat conservatively • Encourage employer liaison • Avoid kneeling • Consider infection Complications • Infection/Septic bursitis • Muscle wasting • Chronic bursitis • Recurrent fluid accumulation • Progressive enlargement of bursa History • Comprehensive nursing assessment • Swelling after kneeling • Blow/Pressure to patella • Penetration of skin over patella • Previous history of crystal arthritis • Occupation Assessment (According to Competency) • Well defined prepatellar swelling • Knee joint to exclude other pathology, compare with other side • Local tenderness • Evidence of penetration/foreign body • Toxicity/Febrile • Job task analysis Differential Diagnosis • Inflammation of knee joint, patella tendon • Effusion knee joint • Septic bursitis • Crystal arthritis • Injury to patella • Reiter’s disease Action Plan • Rest • Restriction of precipitating activity • Consider NSAIDs, analgesia Referral to specialist medical practitioner: • If no history of knee pressure • Febrile/Suspected sepsis • Not resolving • Recurrent fluid accumulations • Knee joint involvement Onward Referral • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Refer to medical practitioner for investigation and diagnosis, especially where there are any neurological features, suspicion of arthritis or tendon rupture. Patient may require a specialist orthopaedic consultation • Refer for task analysis – gradual return to full duties • Patients, especially the elderly living alone, may require assessment of ADLS and IADLS via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Refer to physiotherapy, acupuncture, occupational health nurse or occupational therapist Patient Education • Best prevented by avoiding direct blows to the knee cap area and prolonged kneeling • Protective knee caps 81 Achilles Tendonitis/Sprain Achilles Tendon Identifier Read Codes Key Points 82 Achilles Tendonitis/Sprain Achilles Tendon N2174/S5504 • Differentiate acute from gradual process • Prolonged recovery common • Heel raise important • Consider risk of DVT • Advice to employer Complications • Recurrence • Rupture, particularly after steroid injection • Steroid depositions History • Comprehensive nursing assessment • Speed of onset • Niggling pain • Tightness • Excessive morning stiffness • Previous injury or injection • Gout Assessment (According to Competency) • Compare with other side • Swelling of tendon • Pain on dorsiflexion • Crepitus • Tight calf • Tendon tenderness • Calf squeeze to exclude tendon rupture (negative Thompson test) • Get patient to tiptoe on both feet, then put all weight on injured foot – if unable to do so, tendon rupture Differential Diagnosis • Rupture of achilles tendon • Bursitis (retro calcaneal) • DVT • Gout • Bruising • Osteo or rheumatoid arthritis • Inflammatory arthropathy • Sever’s disease Investigation In consultation with medical practitioner: • Ultrasound if not settling or if uncertain of tendon integrity Action Plan Referral to medical practitioner if: • Suspected or complete rupture • Suspected DVT • No improvement over 2 weeks • Previous rupture Other options include: • Physiotherapy • Heel raise • Moderation of activity • Calf stretching once pain reducing • Icing • Crutches • Podiatry for biomechanical assessment +/– orthotics • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess level of independence and refer appropriately continued … Identifier Read Codes Patient Education Achilles Tendonitis/Sprain Achilles Tendon continued N2174/S5504 continued • Educate about prevention by stretching calf muscles and achilles tendons before exercise • If achilles tendons or calf muscles are tight, stretch twice a day 83 Synovitis/Tenosynovitis Identifier Read Code Key Points Synovitis/Tenosynovitis N220. • Tenosynovitis involves inflammation of the tendon and tendon sheath • Examples include De Quervain’s tenosynovitis and trigger finger • Overuse (repetitive stress), poor technique or following on from an acute injury are all causes of tenosynovitis • Beware infection (joint or sheath) • Rest is very important • Consider conditions such as hypothyroidism or pregnancy • Diagnosis <18 years of age rare • Identify and modify any precipitating activity Complications • Chronic pain state • Partial tear or rupture of the tendon (especially following steroid injection) • Occupational problems History • Comprehensive nursing assessment • Pain and/or swelling in or around tendon • Pain in forearm/wrist • Pain brought on by prolonged activity or repetitive movements • Work, sports, hobbies assessment • Local tenderness and swelling, especially along tendon sheath • Local heat • Crepitus (tendons) • Tendon/Joint function • Psychosocial yellow flags (e.g. vague or non-specific pains) De Quervain’s tenosynovitis: • Thickening and tenderness of the involved tendon sheath. Crepitus is only present with acute inflammation • Pain reproduced upon Finkelstein’s test, in which the patient closes the fingers around the flexed thumb in the palm, and the examiner gently ulnar-deviates the patient’s wrist, stretching the involved tendons Trigger finger: • Tenderness at the proximal end of the tendon sheath, in the distal palm • Palpable tendon thickening and nodularity may be present • Crepitation and catching of the tendon may be observed when the finger is flexed Differential Diagnosis • Carpal tunnel syndrome • Hypothyroidism/Pregnancy • Inflammatory arthritis • Joint sprain/fracture • Nerve entrapment local/distant • Old carpal injury • Ganglion • Gout/Pseudogout • Soft tissue infections Investigation In consultation with medical practitioner: • X-ray • Nerve conduction tests continued … 84 Identifier Read Code Action Plan Synovitis/Tenosynovitis continued N220. continued • Identify and remove/reduce stressors • Rest • Anti-inflammatory gel • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Assess level of independence and refer accordingly Other options include: • NSAIDs • Physiotherapy • Workplace assessment by qualified person (occupational therapist, occupational health nurse) • Occupation advice Onward Referral Refer to medical practitioner if: • Not settling with conservative management within 2-3 weeks • Associated medical problems or inflammatory condition Patient Education • Avoid activities that overuse thumb and wrist • Rotation of duties so that not working for extended periods using same muscles repetitively 85 86 Section Four: Sprains/Strains Overview.........................................................................................................................................................89 Red and Yellow Flags....................................................................................................................................89 Medical Certification for Reduced Work Capacity/Time off Work....................................................................89 Muscle Strains.............................................................................................................................................90 Ligament Sprains.........................................................................................................................................90 X-Ray Rules..................................................................................................................................................90 Soft Tissue Injury..........................................................................................................................................91 Chronic Neck Pain........................................................................................................................................92 Codes and injuries N142./S572./N143. Low back Pain, Acute Back Pain – Lumbar, Lumbago/Lumbar Sprain/Sciatica......................95 N131./S570. Neck Pain/Neck Sprain.......................................................................................................100 S5y3. Sprain Rib..........................................................................................................................103 S500. Sprain Acromio-Clavicular Ligament...................................................................................106 S507./S504./S503./S502. Shoulder/Rotator Cuff Sprains and Tendon tears (Includes Infraspinatus).....................................................................................................108 S51.. Sprain Elbow/Forearm........................................................................................................110 S5Q2./S5Q4. Rupture of Supraspinatus/Biceps Tendon...........................................................................112 S52../S524. Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains) Sprain Tendon Wrist or Hand..............................................................................................114 N2264 Hand/Wrist Flexor Tendon Rupture.....................................................................................116 S5204 Sprain Radial Collateral Ligament (Thumb).........................................................................118 S522. Sprain Thumb....................................................................................................................120 S523./S5513 Sprain Finger......................................................................................................................122 S53../S535. Sprain Hip/Thigh, Sprain Hamstring...................................................................................124 S533. Sprain/Strain Quadriceps Tendon......................................................................................126 S460./S461. Meniscal Tear (Medial/Lateral)...........................................................................................128 S5400/S541. Sprain Collateral Ligament Knee.........................................................................................130 S542. Sprain Cruciate Ligament Knee...........................................................................................132 S550. Sprain Ankle (Lateral Ligaments)........................................................................................134 S5512/S5513 Sprain Metatarso-Phalangeal Joints/Interphalangeal Joint..................................................136 87 88 Sprains/Strains Overview ACC/National Health Committee Red and Yellow Flags Red Flags for potentially serious conditions: • F eatures of cauda equina syndrome (especially urinary retention, bilateral neurological symptoms and signs, saddle anaesthesia) • Significant trauma • Weight loss • History of cancer • Fever • IV drug use • Steroid use • Patients aged >50 years • Severe, unremitting night-time pain • Pain that gets worse when patient is lying down Yellow Flags Psychosocial factors that increase the risk of developing or perpetuating long-term disability and work loss associated with LBP: • • • • • • • ttitudes and beliefs about back pain A Behaviours Compensation issues Diagnostic and treatment issues Emotions Family Work Medical Certification for Reduced Work Capacity/Time Off Work All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. (Consider whether able to perform some work tasks with injury.) Incapacity includes any restrictions on ability to complete normal pre-injury work tasks/hours. • ACC45 Injury Registration and Claim Form on the patient’s first visit – this certifies incapacity for the first 14 days • Short term depending on occupation: 1-2 days preferably, at least less than a week • Certificate for temporary alternative work with clear indication of functional capacity • ACC18 Ongoing Medical Certificate (if an ACC45 has already been completed for this injury) – certifies ongoing limitations and incapacity, with changes in diagnosis, complications and timeframes • ACC18 can usually be issued for maximum of 13 weeks 89 Muscle Strains Grade 1: • Clinical features: localised pain but no loss of strength • May be small amount of bruising • Pathology: small number of muscle fibres torn Grade 2: • Clinical features: pain, swelling, bruising • Strength is reduced and movement is limited by pain • Pathology: tear of significant number of muscle fibres Grade 3: • Clinical features: significant loss of movement/strength • May be no pain • Pathology: complete tear of muscle. Seen most frequently at musculotendinous junction Predisposing factors in development of muscle strains: • • • • • Insufficient flexibility Excessive muscle tightness Fatigue, overuse, inadequate recovery Muscle imbalance Inadequate warm-up Ligament Sprains Grade 1: • Ligament sprain with no laxity (pain only on stressing) Grade 2: • Ligament sprain with laxity but definite end point Grade 3: • Ligament sprain with laxity but NO definite end point (rupture) Additional points to consider: • Children <12 years rarely sprain ligaments • Elderly patients are much more likely to fracture bones than sprain ligaments • Elderly patients are prone to suffer stiffening of their joints e.g. frozen shoulder, even in more peripheral injuries and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most strains • Watch for tendon ruptures in older patients X-Ray Rules 90 Red Flag Prolonged sym ptoms >6 weeks Ottawa Ankle Rules of appropriate re habilitation (p ain, sw el lin g, an • X-ray if: talgia, decrease d range of motio n) suggestive – Unable to bear weight (take 4 steps) at time of injury and at examination of osteochondra l injury/capsu – Bone tenderness at posterior edge or tip of either malleolus litis. Re-X-ray and re fer: – Bone tenderness over the navicular or base of 5th MT • All children <12 years • Elderly patie nts Ottawa Knee Rules • X-ray if: – Patient >55 years – Tenderness present at head of fibula – Isolated tenderness over patella – Inability to flex knee to 90° – Inability to transfer weight for 4 steps both immediately after injury and at examination • Exclusion criteria: – Age <18 years – Isolated superficial injuries being re-evaluated – Patients with altered levels of consciousness, paraplegia or multiple injuries Pittsburgh Knee Rules • Indicate radiography if the mechanism of injury is blunt trauma or a fall, and either: – The patient is <12 or >50 years of age; or Red Flag – The injury causes an inability to walk 4 weight-bearing steps at examination If the knee op ens to valgus/v • Exclusion criteria: arus stress while fu lly extended, th – Knee injuries that occur more than 6 days before presentation is implies a post erior capsular – Patients with only superficial lacerations and abrasions tear of the knee and should be refe rred – Those with a history of previous surgeries or fractures on the affected knee • Reassessments of the same injury Soft Tissue Injury What to do immediately following a soft tissue injury. This advice does not apply to neck and back injuries. RICE • Rest – reduces further damage, stop activity as soon as the injury occurs. Avoid as much movement as possible to limit further injury. Don’t put any weight on the injured part • Ice – apply ice packs to the contusion – this cools the tissue and reduces the pain, swelling and bleeding. Place ice wrapped in a damp towel onto the injured area – do not put ice directly onto bare skin. Hold the ice pack in place with a bandage. Keep ice on the injury for 20 minutes every 2 hours for the first 48 hours (not necessary to interrupt sleep for this) • Compression – firm bandaging helps to reduce the bleeding and swelling. Bandage the injury between ice treatments • Elevation – helps to stop the bleeding and reduce swelling; raise the injured area on a pillow for comfort and support. Keep the injured area raised as much as possible • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin Avoid HARMS for 72 hours after injury Avoid HARMS • Heat – avoid hot baths or showers, saunas, hot water bottles, heat packs and liniments. Heat increases bleeding at the site • Alcohol – can mask the pain of the injury, which may delay their seeking appropriate treatment. Alcohol increases bleeding and swelling at the injury site and delays healing • Running – or any form of exercise may cause further damage. Do not resume exercise within 72 hours of the injury unless on the advice of a medical practitioner • Massage – can cause an increase in bleeding and swelling. If the area is massaged within the first 72 hours, it may take longer to heal 91 Chronic Neck Pain Identifier Read Code Key Points Chronic Neck Pain • Take a clinical history, including circumstances surrounding onset and conduct an examination to identify the need for investigation and specific therapy • Clinical localisation of the pain source is sometimes possible. There are fewer disc lesions. • The mechanism of injury is important in the severity of injury e.g. MVA, scrum collapse • Compared with the lumbar spine, the cervical spine is significantly more flexible and: – Prone to acceleration/deceleration injury (whiplash) – Disc lesions are less common – Manipulation is easier but potentially more dangerous The possibility of adverse effects is hard to predict • Beware of: – Vertebral artery spasm (do not manipulate) – Fractures, especially with underlying disease – Rheumatoid arthritis – Neurological signs Complications • Chronic neck pain is a serious clinical development, and prevention of chronicity requires a high priority. The best opportunity for preventing chronicity occurs within the first few weeks • Chronic neck pain should not be treated as if it were acute or recurrent neck pain, since this leads to serial investigations and ineffective therapy • Vertebral artery spasm. Beware patients with symptoms of vertebral artery insufficiency (syncope/light-headedness with turning, looking up or sustained position) • Neurological sequelae • Acute nerve root compression syndrome History • Comprehensive nursing assessment • Time relationship of symptoms to injury • The mechanism of injury is important in assessing likely severity of injury e.g. MVA, scrum collapse • Past history – associated diseases e.g. rheumatoid arthritis, polymyalgia rheumatica, cerebrovascular disease Assessment (According to Competency) • Diagnostic triage • Establish date and time of injury, if possible • Identify Red Flags • Medical referral for neurological exam mandatory if pain/related symptoms present below shoulder level • CVS examination may be needed • Psychosocial barriers to recovery (refer to Yellow Flags ) Goals for the assessment: 92 • Obtain a baseline for the level of function and activity • Alleviate uncertainty about the regional nature of neck pain • Exclude neurological/CVS catastrophe • Vertebral artery insufficiency: syncope/light-headedness with turning, looking up or sustained position • Ability to carry out occupation/alternative work continued … Identifier Read Code Differential Diagnosis Chronic Neck Pain continued continued • Soft tissue injury, non-specific neck pain • Myelopathy, occlusion of vertebral artery, fracture • Chronic neck pain (requires different management) • Non-injury neck pain e.g. rheumatoid arthritis, polymyalgia rheumatica Investigation • X-ray, FBC and ESR/CRP if signs or symptoms of serious disease are ) present (Red Flags • The majority of cervical spine injuries do not need radiological imaging unless Red Flags are present Action Plan • Manual techniques such as manipulation are potentially dangerous. The possibility of adverse effects is hard to predict • Contraindications to manipulation include: – Severe osteoporosis – Metastases – Vertebral artery insufficiency – Rheumatoid disease of neck – Acute nerve root compression – Children/Infants – Last trimester pregnancy – Bleeding disorder Initial treatment and management: • If no Red Flags or fracture: Provide (or refer to appropriately qualified provider): • Explanation and reassurance (stress the importance of rest for 48 hours only if possible) • Advice on staying active – Directive to use short-term alteration for everyday and work activities – Explore opportunities for demedicalising neck pain – Encourage directed self-management approach Symptom control: • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Manipulation from experienced/qualified provider for first 4-6 weeks maximum. Note contraindications to manipulation • Review and monitor progress within 1 week Medical certification: • Short term depending on occupation: 1-2 days preferably, at least less than 1 week • Certificate for temporary alternative work with clear indication of functional capacity Ongoing treatment and management: • Review the patient’s pain and disability (activity limitation) and response to treatment at 1-2 days; refer to medical practitioner if indicated • Check for signs and symptoms of serious disease (Red Flags ) and psychosocial barriers to recovery (Yellow Flags ). Consider referral or further diagnostic work-up – see Investigation • Repeat initial management options • Consider referral to a goal-oriented multidisciplinary team who will: – Reactivate the patient – Provide symptom control – Enhance coping and self-management – Deal with psychosocial barriers to returning to work or normal activity level • Where possible, discuss with employer continued … 93 Identifier Read Code Onward Referral Other Referral (note flags for manipulation) 94 Chronic Neck Pain continued continued • Pain that fails to settle in 1-2 days • Serious spinal pathology • Presence of Red Flags • Time off work required • Chiropractor • Osteopath • Physiotherapy • Psychologist or vocational management consultant only if significant psychological barriers to recovery and return to work • Home help • Occupational therapy Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica Identifier Read Codes Key Points Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica N142./S572./N143. • An adequate clinical history and examination should be sufficient to identify the need for investigation and specific therapy • Giving patients a clear message about the natural history of pain without the use of appropriate labels that may cause anxiety or fear of activity is important • Unless specifically targeted with appropriate preventive interventions, about 7-10% of patients with acute LBP remain disabled and become chronic • The mechanism of injury and patient age are important in the severity of the injury • The majority of all clinically significant lower limb radiculopathy due to disc herniation involves the L5 or S1 nerve root at the L4/5 or L5/S1 disc level • Primary care practitioners have a critical role in preventing the development of chronic pain-related disability • For further information refer to the New Zealand Acute Low Back Pain Guide The essential components of managing acute LBP are: • Identify or exclude major pathology – Red Flags • Use appropriate symptom control • Return to usual activities as soon as possible • Engage the patient in self-help. Note this usually requires a 2nd consultation Complications • Chronic LBP causes extensive suffering to individuals and their families. The restoration of function and return to usual activity and work are essential parts of preventing long-term disability • Recovery from chronic LBP is difficult and demands high levels of resources. Prevention of chronicity requires high prioritisation. Note that the best opportunity for preventing chronicity occurs within the first few weeks • Chronic LBP should not be treated as if it were acute or recurrent LBP, since this leads to serial investigations and ineffective therapy • Presence of underlying pathology e.g. spondylolysis, spondylolisthesis History • Comprehensive nursing assessment • Circumstances of injury: mechanism and timing of injury related to symptom development • Occupation • Other diseases e.g. osteoporosis, neoplasm continued … 95 Identifier Read Codes Assessment (According to Competency) Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica continued N142./S572./N143. continued • Area/Level of dysfunction • Bladder and bowel function • Saddle area sensation • Check for Red and Yellow Flags • Goal for the assessment: – Obtain a baseline for the level of function and activity At follow-up the need to screen for psychosocial factors should be considered if there is a problem noted with the patient’s response to pain or recovery. The goal is to identify factors that increase the probability of long-term disability and work loss, and areas where specific intervention is required. The following factors are predictive of poor outcomes: • Belief that back pain is harmful or potentially disabling • Fear-avoidance behaviour and reduced activity levels • Tendency to low mood and withdrawal from social interaction • Expectation of passive treatment(s) rather than a belief that active participation will help Assess psychosocial barriers to recovery: Suggested questions (to be phrased in your own style) • Have you had time off work in the past with back pain? • What do you understand is the cause of your back pain? • What are you expecting will happen? • How is your employer responding to your back pain? Co-workers? Family? • What are you doing to cope with back pain? • When do you think that you will return to work? Differential Diagnosis • Non-specific back pain • Nerve root pain • Red Flags (refer Investigation) • Cauda equina syndrome • Chronic LBP (requires different management) Investigation • X-ray, FBC and ESR/CRP if Red Flags present • Radiological investigations (X-rays and CT scans) can cause harm from radiation-related effects and should be avoided unless necessary. Many people without symptoms show abnormalities on X-ray and scan. The chances of finding coincidental disc prolapse increase with age continued … 96 Identifier Read Codes Action Plan Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica continued N142./S572./N143. continued NB: Discuss all LBP, acute back pain – lumbar, lumbago/lumbar sprain/ sciatica with a medical practitioner Initial treatment and management (in discussion with medical practitioner): Refer immediately if: • Bladder or bowel dysfunction • Altered sensation in saddle area • Serious spinal pathology • Nerve root pain that has failed to settle quickly • Neurological deficit e.g. foot drop • Persistent back pain <20 years of age If no Red Flags : • Provide: – Explanation – Reassurance – Advice on staying active – see Patient Education – Directive to use short-term alteration for everyday and work activities – Discuss employer’s alternative duties programme • Encourage and educate the patient to mobilise early, once Red Flags have been excluded. Explain that no more harm will occur from early mobilisation Explore opportunities for demedicalising LBP: NB: this always requires a 2nd consultation • Encourage directed self-management • Provide information • Distribute a copy of ACC1945 Don’t Take Back Pain Lying Down – Self management guide to acute low back pain Symptom control: • May require rest, but no longer than 24-48 hours • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Manipulation – refer to a provider with a demonstrated record in providing symptom control as an adjunct to increasing function, and stipulate a time period (preferably less than 4-6 weeks) for reviewing the patient and ceasing the course of therapy. Review and monitor progress within 1 week Ongoing treatment and management, in discussion with a medical practitioner: • Review and monitor progress regularly 1-2 days following the initial consultation • Where possible, discuss with employer • Conduct a comprehensive reassessment including the patient’s pain and disability (activity limitation) and response to treatment • Recheck for Red and Yellow Flags • Repeat initial management options • Referral to an allied health professional Reactivation, or reduction of activity intolerance: • Patients who have not returned to usual activities or work, and failed to respond to treatment may require reactivation • Consider referral to a goal-oriented multidisciplinary team who will: – Reactivate the patient – Provide symptom control – Enhance coping and self-management – Deal with psychosocial barriers to returning to work or normal activity level continued … 97 Identifier Read Codes Onward Referral Patient Education Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica continued N142./S572./N143. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Case management if no RTW after 2 weeks, consider reactivation • Patients, especially the elderly living alone, may require assessment of ADLs and IADLs via social rehabilitation assessment • Consider child care/home help for primary parent of young children • Occupational therapy – return to work plan/work site assessment • Osteopath • Physiotherapy • Chiropractor • Psychologist or vocational management consultant if significant psychosocial barriers to recovery and return to work Activity advice and reassurance: • Advise patient to increase progressively their physical activity according to an agreed plan rather than be guided by their pain level • Bed rest should be avoided, particularly prolonged bed rest, which is harmful • Avoid low or soft chairs • Wear comfortable, supportive shoes with a low heel • Staying active and continuing usual activities such as walking, swimming, non-contact sports, and work (with modifications if required) usually result in a faster recovery from symptoms, less chronic disability and less time off work • Reassure patients that full recovery is likely and that the activity that triggered the episode (often a common action like a bend or twist) will not cause further injury • Advise patients that they are the best person to manage their LBP • Harmful treatment1 includes use of narcotics or diazepam, bed rest for more than 2 days, bed rest with or without traction, manipulation under GA, and a plaster jacket • Continue analgesia – paracetamol and NSAIDs – at regular intervals rather than “as required” • Promote secondary prevention: eliminate obesity and smoking, increase normal physical activity and adopt sensible manual handling techniques within the ability of the individual Ongoing management: • Advise patient to stay active and resume usual activities • Encourage patient to link into a provider e.g. physiotherapist, for specific advice on activities that may cause problems • Support return to activity with optimal pain control • If problems persist, return for assessment to identify and address barriers to recovery such as excessively heavy or prolonged work; problems with treatment, rehabilitation or compensation; and psychological factors, known as Yellow Flags continued … 98 1. ACC Review Acute Low Back Pain – Part 2 – Clinical Management Identifier Read Codes Patient Education continued Low Back Pain, Acute Back Pain – Lumbar, Lumbago/ Lumbar Sprain/Sciatica continued N142./S572./N143. continued Return to Work: • Encourage patient to continue working normally • Ensure work surface at a comfortable height • Determine if alternative work duties are necessary • Work with your health care provider to identify barriers and address them up front • Consult with medical practitioner and consider if a gradual return to work is appropriate • Advise on timetables for achievement (e.g. how long temporary changes may be required) • Return for medical assessment to monitor recovery and symptom control and modify strategies that are not working • Advise patient to make an appointment to discuss work issues with their ACC case manager 4-6 week follow-up • After 4 weeks if the patient has not resumed normal activities return to a medical practitioner for a formal assessment (to include Red and Yellow Flags) • After 6 weeks, if progress is still delayed, the medical practitioner should again assess the patient • The patient may need to see a specialist if there has been no progress 99 Neck Pain/Neck Sprain (see Overview and Chronic Neck Pain) Identifier Read Codes Key Points Neck Pain/Neck Sprain (see Overview and Chronic Neck Pain) N131./S570. • Take a clinical history, including circumstances surrounding onset, and conduct an examination to identify the need for investigation and specific therapy • Clinical localisation of the pain source is sometimes possible. There are fewer disc lesions • The mechanism of injury is important in the severity of injury e.g. MVA, scrum collapse • Compared with the lumbar spine, the cervical spine is significantly more flexible and: – Prone to acceleration/deceleration injury (whiplash) – Disc lesions are less common – Manipulation by qualified health professions is easier but potentially more dangerous • Beware of: – Vertebral artery spasm (do not manipulate) – Fractures, especially with underlying disease – Rheumatoid arthritis – Neurological signs Complications • Chronic neck pain is a serious clinical development, and prevention of chronicity requires a high priority. The best opportunity for preventing chronicity occurs within the first few weeks • Chronic neck pain should not be treated as if it were acute or recurrent neck pain, since this leads to serial investigations and ineffective therapy • Vertebral artery spasm. Beware patients with symptoms of vertebral artery insufficiency (syncope/light-headedness with turning, looking up or sustained position) • Neurological sequelae • Acute nerve root compression syndrome History • Comprehensive nursing assessment • The mechanism of injury is important in assessing likely severity of injury e.g. MVA, scrum collapse • Past history – associated diseases e.g. rheumatoid arthritis, polymyalgia rheumatica, cerebrovascular continued … 100 Identifier Read Codes Assessment (According to Competency) Neck Pain/Neck Sprain (see Overview and Chronic Neck Pain) continued N131./S570. continued Refer and discuss treatment with medical practitioner • Identify Red Flags • Medical referral for neurological exam mandatory if pain/related symptoms present below shoulder level • CVS examination by medical practitioner may be needed • Psychosocial barriers to recovery (refer to Yellow Flags ) • At follow-up the need to screen for psychosocial factors should be considered if there is a problem noted with the patient’s response to pain or recovery. The goal is to identify factors that increase the probability of long-term disability and work loss and areas where specific intervention is required. The following factors are predictive of poor outcomes: – Belief that pain is harmful or potentially disabling – Fear-avoidance behaviour and reduced activity levels – Tendency to low mood and withdrawal from social interaction – Expectation of passive treatment(s) rather than a belief that active participation will help • Assess psychosocial barriers to recovery: (suggested questions to be phrased in your own style) – Have you had time off work in the past with neck pain? – What do you understand is the cause of your neck pain? – What are you expecting will happen? – How is your employer responding to your neck pain? Co-workers? Family? – What are you doing to cope with neck pain? – When do you think that you will return to work? Goals for the assessment: • Obtain a baseline for the level of function and activity • Alleviate uncertainty about the regional nature of neck pain • Vertebral artery insufficiency: syncope/light-headedness with turning, looking up or sustained position • Ability to carry out occupation/alternative work Differential Diagnosis • Soft tissue injury, non-specific neck pain • Myelopathy, occlusion of vertebral artery, fracture • Chronic neck pain (requires different management) • Non-injury neck pain e.g. rheumatoid arthritis, polymyalgia rheumatica Investigation X-ray, FBC and ESR/CRP if signs or symptoms of serious disease are present (Red Flags ): • The majority of cervical spine injuries do not need radiological imaging unless Red Flags present continued … 101 Identifier Read Codes Action Plan Onward Referral 102 Neck Pain/Neck Sprain (see Overview and Chronic Neck Pain) continued N131./S570. continued Manual techniques such as manipulation are potentially dangerous. The possibility of adverse effects is hard to predict. Refer and discuss initial treatment and management with a medical practitioner. If no Red Flags or fracture, provide: • Explanation and reassurance (stress the importance of rest for 48 hours only, if possible) • Advice on staying active – Adapt/Alter everyday and work activities – Explore opportunities for demedicalising neck pain – Encourage self-management approach Symptom control: • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Review and monitor progress within 1 week • Refer and discuss ongoing treatment and management with a medical practitioner Ongoing treatment and management: • Review the patient’s pain and disability (activity limitation) and response to treatment at 1-2 days • Check for signs and symptoms of serious disease (Red Flags ) and ). Consider referral or psychosocial barriers to recovery (Yellow Flags further diagnostic work-up – see Investigation • Repeat initial management options • Consider referral to a goal-oriented multidisciplinary team who will: – Assist the patient with rehabilitation – Provide symptom control – Enhance coping and self-management – Deal with psychosocial barriers to returning to work or normal activity level – Where possible, discuss with employer • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether some work tasks can be done with injury Discuss all neck pain/neck sprain with a medical practitioner • Presence of Red Flags • Presence of Yellow Flags • Chiropractor • Osteopath • Physiotherapy • Psychologist or vocational management consultant, only if significant psychological barriers to recovery and return to work • Home help • Occupational therapy • Consult with medical practitioner and consider if a gradual return is necessary • Advise on timetables for achievement (e.g. how long temporary changes may be required) • Return for medical assessment to monitor recovery and symptom control and modify strategies that are not working • Advise patient to make an appointment to discuss work issues with their ACC case manager Sprain Rib Identifier Read Code Key Points Sprain Rib S5y3. • This code includes costo-vertebral, costo-chondral and chondro-sternal sprains • Good history and examination of the whole patient are essential • Review the patient and analgesia • Beware children – less fracture chance after major trauma = higher risk of intrathoracic damage • Rib sprains are unlikely to have significant associated pathology • Pain relief is the mainstay of treatment • Investigation is usually not needed Complications • Respiratory – pneumothorax, haemothorax, pneumonia (hypoxia, hypotension, pain) • Heart (cardiac contusion, haemopericardium, tamponade) • Skeleton – flail chest, fractures, dislocations (especially ribs, sternal joints) • Abdomen – perforated viscus, splenic contusion, renal contusion, liver • Neurological – subclavian, spinal, intercostal nerves • Vascular – intercostal, subclavian vessels, haemoperitoneum • Infection – fever, sepsis History • Comprehensive nursing assessment • Mechanism of injury: direct blow/AP crush/fall from height – may be a good indicator of more severe pathology • Pleuritic chest pain, often localised • Pain – location, nature, radiation, aggravating/relieving factors • Check for aggravating factors in past history: COPD, neoplasias, smoker, past trauma, asthma • Check for important symptoms e.g. haemoptysis • Exclude other causes e.g. DVT • 1st rib sprain may be associated with brachial plexus symptoms continued … 103 Identifier Read Code Assessment (According to Competency) Sprain Rib continued S5y3. continued Discuss all but trivial injuries with medical practitioner Airway with cervical spine injury Note any abnormal airway sounds, especially stridor Breathing • Rate and depth • Symmetry of chest wall movement • Equal breath sounds on auscultation • Accessory muscle use • Observe for cyanosis, change in colour • Trachea midline • Note any bruising, contusion, grazing Circulation • Heart rate and rhythm • BP • Skin colour and warmth. Patient may be pale and sweaty • Observe for signs of shock Secondary survey • Observe for any abnormalities of the chest wall • Palpate abdomen for pain, rigidity, guarding. Risk of spleen or liver injury • Listen for presence of bowel sounds • Complete full secondary survey to ensure no other injuries Differential Diagnosis • Contusion • Respiratory – infection/pleurisy/pulmonary embolus (see Complications) • Cardiac – beware myocardial infarction, pericarditis • Fracture – stress (rowers), sternum, ribs especially 1st ribs, spine • Musculoskeletal – chronic conditions e.g. osteoarthritis, costochondritis, ankylosing spondylitis • Gastrointestinal – GORD, PUD, hepatitis, biliary • Dislocation: costo-vert or costo-sternal/costo-costal • DVT, pulmonary embolus • Costochondritis Investigation • Usually not necessary • Oxygen saturation if indicated • Refer for X-ray and reporting as appropriate • X-ray chest – expiratory and oblique (if severe fracture suspected) • Abdomen – erect, supine, lateral decubitus, cervical spine, thoracic spine, sternum • May need CT views if 1st rib involved Action Plan Discuss with medical practitioner: • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Physiotherapy • Resuscitation – airways, breathing and circulation, primary and secondary surveys • Mobilisation continued … 104 Identifier Read Code Onward Referral Patient Education Sprain Rib continued S5y3. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • All but trivial injuries to the ribs • Incomplete assessment/diagnosis unclear • Impaired ventilation – pneumothorax, flail chest (discuss all) • Cardiovascular shock • Impaired nerve function • Impaired skeletal integrity – 1st rib fracture, multiple rib fractures, sternal dislocation, discuss spinal fractures • Physiotherapy • Osteopath • Chiropractor • Acupuncture • Continue use of regular pain relief e.g. paracetamol and NSAIDs • Encourage frequent deep breathing and coughing exercise • Support the chest with a pillow when coughing • Return if increased cough, respiratory difficulty or fever • Return if pain does not settle 105 Sprain Acromio-Clavicular Ligament Identifier Read Code Key Points Sprain Acromio-Clavicular Ligament S500. • Always X-ray, including weight bearing • Children <12 years rarely sprain ligaments • Early physiotherapy to mobilise the synovial AC joint and supervise return to sport • Elderly patients more likely to fracture than sprain • Elderly more prone to stiffening e.g. frozen shoulder • RICE therapy early • Watch tendon rupture in elderly Complications • Non-healing/Non-union • Chronic recurrent injury • Unstable joints if Grade 3 not referred • Delayed rupture of major sprains • Development of tendonitis in partial tendon tear • Damage to underlying structures (neurovascular, tendon, lung) • Frozen shoulder in elderly History • Comprehensive nursing assessment • Blow or fall onto shoulder • Contact sport • Repetitive action • Previous shoulder dislocation • Associated fracture Assessment (According to Competency) • Define Grades 1, 2, 3 sprains (see Sprains/Strains Overview) • Compare with other side • Tender AC joint • Local deformity/swelling • Step or instability in AC joint • Grade 2 sprains may be difficult (have only a step deformity + too tender to elicit laxity) • Full range of movement • Pain on horizontal adduction and weight bearing • Weakness • Screen neck movement Differential Diagnosis • Fractured clavicle, humeral neck • Dislocated shoulder • Bruising • Congenital • Cervical spine injury • Supraspinatus/Acromial bursa injury Investigation • Refer for X-ray and reporting as appropriate • X-ray for AC joint injuries to determine grade in association with clinical findings continued … 106 Identifier Read Code Action Plan Sprain, Acromio-Clavicular Ligament continued S500. continued Refer and discuss with medical practitioner: • Physiotherapy for Grades 2 and 3 to mobilise the joint early and supervise return to sport • RICE 24-48 hours • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Rest (avoid sport and lifting) • Broad arm sling • Grades 1-2 – Rest 2-3 weeks – as pain allows • Grade 3 – Rest up to 6 weeks – Refer if no improvement after 2 weeks Onward Referral • Some patients will require time off work because of their injury. • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • All AC ligament injuries • Diagnostic uncertainty • AC joint dislocations • Physiotherapy for all grades as above Patient Education • Continue regular analgesia e.g. paracetamol, avoid aspirin • Attend physiotherapy promptly • Instruct in use of a sling – see Practical Techniques in Injury Management Casts and Splints: ACC2373 • Wriggle fingers on affected arm frequently • Gently exercise the nearby joints, including the elbow, wrist, hand as comfort allows • No contact sport or lifting until cleared by physiotherapist • RICE • If the pain or swelling has not resolved significantly within 48 hours, obtain further assessment • Avoid HARMS (within the first 72 hours) 107 Shoulder/Rotator Cuff Sprains and Tendon Tears (Includes Infraspinatus) Identifier Read Codes Key Points Shoulder/Rotator Cuff Sprains and Tendon Tears (Includes Infraspinatus) S507./S504./S503./S502. • The R/C is a thin sheet of tissue made up from tendons arising from scapular muscles including infraspinatus, teres minor, subscapularis and supraspinatus • The function of the R/C is to stabilise the glenohumeral joint during power movements performed by the prime mover muscles (e.g. pectoralis major, latissimus dorsi and deltoid) • The secondary function of the R/C is rotation and abduction of the glenohumeral joint and this is used as the clinical method of testing the R/C to ascertain which of the R/C muscles/tendons is predominantly injured • Patients >40 years with a significant shoulder injury are more likely to have a tear of their R/C • 50% of patients >40 years, with a dislocated shoulder, will have an R/C tear • Significant R/C tears do NOT heal (due to poor blood supply) and require surgical repair • Prompt referral to a medical practitioner should be made if an R/C tear is suspected • Ultrasound is a good investigation (always request comparison of both sides) for establishing the degree of R/C tear (can be operator dependent) • Early mobilisation • RICE therapy early Complications • Chronic pain and inflammation/tendonitis • Permanent loss of function. The ability to repair an R/C tear surgically diminishes with time (window of opportunity to repair surgically is optimal in the first 3 weeks) • Instability • Impingement History • Comprehensive nursing assessment • Sports injury e.g. direct blow, throwing injury, fall • Trauma. Refer early significant shoulder trauma in patients >40 years Assessment (According to Competency) Refer and discuss with medical practitioner: • Define Grades 1, 2, 3 (see Sprains/Strains Overview) • Observe – deformity/swelling. Compare both shoulders • Active range of motion: – Abduction – to draw away from the body. Note painful arc if present – Internal rotation – External rotation. Inability to actively externally rotate can indicate significant R/C tear – early referral indicated • Passive range of motion • Resisted movements. Note pain/decreased power • Circulation and sensation • Cervical spine involvement continued … 108 Identifier Read Codes Differential Diagnosis Shoulder/Rotator Cuff Sprains and Tendon Tears (Includes Infraspinatus) continued S507./S504./S503./S502. continued • R/C sprain, sprain shoulder joint = painful arc, decreased active abduction, pain on abduction and rotational active movements • Infraspinatus sprain = pain external rotation and minor active and resisted weakness of external rotation • Supraspinatus tear/R/C tear = painful arc, significant reduction of active and resisted movements e.g. abduction, external rotation, internal rotation • Instability • Fracture • Impingement • Subluxation, dislocation • Subacromial bursitis • Ruptured biceps • Calcific tendonitis Investigation Refer for X-ray and reporting as appropriate: • X-ray • Consider ultrasound – operator dependent Action Plan Discuss initial and ongoing care with medical practitioner: • Broad arm sling if necessary (beware stiffness in elderly) – see Practical Techniques in Injury Management: Casts and Splints: ACC2373: • RICE 24-48 hours • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Physiotherapy/Rehabilitation – mobilise, strengthen and monitor progress • Review at 1 week – if no improvement, refer • Education Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Refer and discuss all shoulder/R/C sprains and tendon tears • Refer Red Flags early: – Suspicion of tear of R/C (from history or clinical or investigations) – Elderly patient • If unsure of diagnosis • If no active movement • If no improvement after 1 week • Physiotherapy • Occupational therapy • Consider home help for the elderly Patient Education • Continue regular analgesia e.g. paracetamol, avoid aspirin • Attend physiotherapy promptly – mobilise, strengthen and monitor progress • Instruct in use of a sling • Wriggle fingers on affected arm frequently • Gently exercise the nearby joints, including the elbow, wrist, hand as comfort allows • No contact sport or lifting until cleared by physiotherapist • RICE – see Sprains/Strains Overview • Avoid HARMS (within the first 72 hours) • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment 109 Sprain Elbow/Forearm Identifier Read Code Key Points Sprain Elbow/Forearm S51.. • Children <12 years rarely sprain ligaments, therefore need X-ray • Elderly patients are much more likely to fracture bones than sprain ligaments, therefore need X-ray • Elderly patients are prone to suffer stiffening of their joints e.g. frozen shoulder even in more peripheral injuries and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most sprains • Watch for tendon ruptures in older patients Complications • Chronic, recurrent injury, tendonitis • Unstable joints if Grade 3 sprains are not referred • Development of tendonitis in partial tendon tear • Chronic pain and loss of function History • Comprehensive nursing assessment • Mechanism of injury: twisting injury with hand fixed, sports injury, trip, fall Assessment (According to Competency) • Decreased range of motion. Unable to extend fully or flex when compared with normal side. Document range of motion • Pain and/or instability when stressing specific ligament or tendon • Bone tenderness • Joint effusion Differential Diagnosis • Fracture – radial head, supracondylar • Dislocation • Infection • Tendon rupture. Biceps or triceps • Tennis elbow • Golfer’s elbow • Triceps tendonitis • Olecranon bursitis Investigation Refer for X-ray and reporting as appropriate: • X-ray (to exclude fracture). Check lateral for fat pad (sail sign) • In children a comparison view of the normal side is often helpful to determine bone/joint pathology Action Plan Refer and discuss initial management and follow-up with medical practitioner: • RICE in first 24-48 hours • Complete pain assessment and provide adequate pain relief by prescription or standing orders • Splint as required for pain relief (broad arm sling or collar and cuff) • Early mobilisation, especially in elderly • Isometric exercise training as prevention of muscle wasting or refer to physiotherapist continued … 110 Identifier Read Code Onward Referral Patient Education Sprain Elbow/Forearm continued S51.. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • All sprains of the elbow/forearm • Fractures • Significant decreased range of motion of elbow persisting 2 weeks after injury • Physiotherapy • Continue regular analgesia e.g. paracetamol, avoid aspirin • Instruct in use of a sling • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows • Remove sling 3-4 times a day for 10 minutes and actively exercise • RICE • Avoid HARMS (within the first 72 hours) • If the pain or swelling has not resolved significantly within 48 hours, return for further assessment 111 Rupture Supraspinatus/Biceps Tendon Identifier Read Codes Key Points Rupture Supraspinatus/Biceps Tendon S5Q2./S5Q4. • Occasionally due to inappropriate use of steroids (abuse or injection) • Refer distal rupture early to specialist • Functional impairment variable • Always examine shoulder and elbow as well • Often misdiagnosed as R/C strain Complications • Loss of function and/or power • Deformity History • Comprehensive nursing assessment • Mechanism of injury – trauma or repetitive strain (weights) • History of corticosteroid injection • Steroid abuse (e.g. weight lifters) Assessment (According to Competency) • Compare with other side • Deformity • Moved muscle belly accentuated by contraction (pain may be absent) • Ecchymosis (bruising) • Range of motion, especially weakness of biceps power • Palpate bicipital groove proximally near attachment to glenoid Differential Diagnosis • Shoulder sprain or contusion • Subacromial bursitis/impingement • R/C strain/tear • Fracture humerus • Pectoralis major tear/strain • Subluxation/Dislocation/Fracture of shoulder • Glenoid labrum tear Investigation Action Plan • X-ray – refer for X-ray and reporting as appropriate Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury Refer and discuss with medical practitioner: • All ruptures of supraspinatus/bicep tendon • Significant loss of function/uncertain diagnosis • Persisting tendonitis • Physiotherapy • Consider home help for elderly Refer and discuss with medical practitioner: • Dependent on diagnosis: – Tendonitis – RICE, NSAIDs – by standing orders or prescriptions, physiotherapy – Rupture (proximal) – RICE, NSAIDs – by standing orders or prescription, high-arm sling 1-2 weeks, physiotherapy – Rupture (distal) – specialist referral stat • Confirm no fracture continued … 112 Identifier Read Codes Patient Education Rupture Supraspinatus/Biceps Tendon continued S5Q2./S5Q4. continued • Continue regular analgesia – paracetamol, avoid aspirin • Attend physiotherapy • Instruct in the use of a sling • Advise patient to wriggle fingers on affected arm frequently • Gently exercise the nearby joints, including the elbow, wrist, hand as comfort allows • RICE • Avoid HARMS (within the first 72 hours) • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment 113 Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains) Sprain Tendon Wrist or Hand Identifier Read Codes Key Points Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains) Sprain Tendon Wrist or Hand S52../S524. • Children <12 years rarely sprain ligaments – X-ray • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • Elderly patients at risk of frozen shoulder with prolonged immobilisation • RICE therapy early • Beware scaphoid fracture in adults • Beware tendon rupture in elderly Complications • Chronic recurrent tendonitis • Unstable joints • Osteoarthritis • Chronic pain • Weakness of grip • Permanent disability History • Comprehensive nursing assessment • Mechanism of injury (acute cause and effect) – fall, trauma, implement, twisting injury while gripping fixed object Assessment (According to Competency) • Deformity • Tenderness • Swelling • Ability to grip • Range of movement (active/passive) • Exclude fracture • Colour/Sensation • Crepitus • Lateral stability Differential Diagnosis • Triangular fibro-cartilage injuries • Tendonitis • Fracture, especially scaphoid, Colles, Bennett’s, growth plate fracture (tender anatomical snuffbox) • Dislocation of inferior radio-ulnar joint or carpal bones (carpal dislocations require urgent referral) • Scapho-lunate disassociation (tenderness in fossa distal to Lister’s tubercle) • Ligamentous instability Investigation Refer for X-ray and reporting as appropriate: • X-ray to exclude fracture/dislocation and consider repeat at 2 weeks if suspicion remains continued … 114 Identifier Read Code: Action Plan Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains) Sprain Tendon Wrist or Hand continued S52../S524. continued • RICE • Complete pain assessment and provide adequate pain relief by prescription or standing orders • Immobilisation by splinting in position of function (early mobilisation in the elderly) • Crepe bandage and broad arm sling • If strong clinical suspicion of scaphoid fracture, refer and discuss with medical practitioner • Discuss the application of POP and further treatment (according to Closed Fracture of Scaphoid S2401) Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Diagnosis unclear • Fracture according to relevant fracture treatment profile • Dislocation (refer urgently if unable to rule out carpal dislocation) • Instability • Neurovascular impairment • No improvement after 2 weeks • Suspected carpal instability • Physiotherapy if persistent • Occupational therapy • Consider home help for the elderly Patient Education • Continue regular analgesia – paracetamol, avoid aspirin • Instruct in use of a splint – see Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Instruct in care of cast – see Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows • Remove splint 3-4 times a day for 10 minutes and actively exercise (especially important in the elderly) • RICE • If the pain or swelling has not resolved significantly within 48 hours, obtain further assessment • Avoid HARMS (within the first 72 hours) 115 Hand/Wrist Flexor Tendon Rupture Identifier Read Code Key Points Hand/Wrist Flexor Tendon Rupture N2264 • Can be secondary to rheumatoid arthritis or osteoarthritis • Occasionally due to inappropriate use of corticosteroids • Can be secondary to laceration proximal to hand and wrist Complications • Osteoarthritis • Joint subluxation • Loss of function • Chronic pain History • Comprehensive nursing assessment • History of corticosteroid injection(s) Assessment (According to Competency) • Loss of function • Swelling • Pain on movement Specific examination for hand/finger flexor tendon rupture or refer to medical practitioner: • Profundus tendon of finger: – Hold PIP joint of examining finger in full extension, ask patient to flex at DIP joint • Sublimis/Superficialis tendon of finger: – Extend and hold all fingers (DIP and PIP joints of all fingers not being tested) then ask patient to flex at PIP joint of the finger being tested • Wrist tendons: – Resist palmar flexion. look and feel for palmaris longus (not always present), flexor carpi ulnaris (test with resisted ulnar deviation and palmar flexion), flexor carpi radialis (test with resisted radial deviation and palmar flexion) Differential Diagnosis • Sprain/Strain • Fracture • Infection • Carpal ligament injury Investigation Refer for X-ray and reporting as appropriate: • X-ray • Check for scapho-lunate instability with bilateral AP clenched fist views Action Plan • In discussion with a medical practitioner, confirm no fracture present • Splint with a position of function splint (DIP and PIP joints extended, MCP 90°, wrist dorsiflexed 45°) • Discuss suspected rupture of any flexor tendon with medical practitioner – will need repair acutely Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Any suspicions of tendon damage/rupture – may require specialist referral • Unclear diagnosis continued … 116 Identifier Read Code Patient Education Hand/Wrist Flexor Tendon Rupture continued N2264 continued • Continue regular analgesia – paracetamol, avoid aspirin • Instruct in use of a splint – see Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows – the longer a joint remains immobile, the greater the possibility that excess swelling may lead to decreased use of the area • Remove splint 3-4 times a day for 10 minutes and actively exercise as above (especially important in the elderly) – also lessens the chance that the hand’s range of movement will be permanently compromised • RICE • If the pain or swelling has not resolved significantly within 48 hours, return for further assessment • Avoid HARMS (within the first 72 hours) 117 Sprain Radial Collateral Ligament (Thumb) Identifier Read Code Key Points Sprain Radial Collateral Ligament (Thumb) S5204 • Less common than UCL sprains • Measure instability in extension by comparison with uninjured side • Mobilisation with physiotherapy must start by 7-10 days • X-ray all but most trivial injuries • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • RICE therapy early • Watch tendon rupture in elderly • Look carefully for associated injuries e.g. dislocation reduced previously, tendon rupture in elderly Complications • Complex regional pain syndrome • Dysfunctional grip from instability • Stiffness • Degeneration of joint surfaces History • Comprehensive nursing assessment • Mechanism of injury – force, degree and direction Assessment (According to Competency) • Assess degree of sprain (Grade 1, 2 or 3 see Sprains/Strains Overview) • Tenderness over joint • Joint stability – passive and active • Tendons • Colour/Sensation • Ability to work/alternative duties Differential Diagnosis • Full rupture • Dislocation reduced elsewhere • Fracture • Tendon injury • 1st MCP joint sprain Investigation Refer for X-ray and reporting as appropriate: • X-ray Action Plan Refer all but trivial injuries to a medical practitioner Ruptured RCL: • Grade 1: – RICE – Thumb spica/elastoplast – Physiotherapy • Grade 2: – Thumb spica – Physiotherapy • Grade 3: – Refer medical practitioner (urgent) Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Refer all but trivial injuries continued … 118 Identifier Read Code Patient Education Sprain Radial Collateral Ligament (Thumb) continued S5204 continued • Continue regular analgesia – paracetamol, avoid aspirin • Instruct in use of a splint – see Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows – the longer a joint remains immobile, the greater the possibility that excess swelling may lead to decreased use of the area • Remove splint 3-4 times a day for 10 minutes and actively exercise (especially important in the elderly) – also lessens the chance that the hand’s range of movement will be permanently compromised • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 119 Sprain Thumb Identifier Read Code Key Points Sprain Thumb S522. (Most Important is Ulna Collateral Ligament Sprain) • Diagnoses include: – UCL sprain (skier’s, gamekeeper’s thumb) – Capsular strain of 1st MCP joint – IP joint strain – Sprain Radial Collateral Ligament Thumb S5204 • Measure instability in extension using comparison with non-injured side • Unstable injuries need referral • Ligament tears (complete) need urgent referral • Mobilisation with physiotherapy must start by 7-10 days • X-ray all but most trivial injuries • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • RICE therapy early • Look carefully for associated injuries e.g. dislocation reduced previously, tendon rupture in elderly Complications • Avulsion fracture proximal phalanx • Complex regional pain syndrome • Dysfunctional grip from instability • Stiffness • Degeneration of joint surfaces History • Comprehensive nursing assessment • Mechanism of injury – force, degree and direction • Capsular sprain of 1st MCP joint: common mechanism is hyperextension or axial compression Assessment (According to Competency) • Assess degree of sprain (Grades 1, 2, 3 see Sprains/Strains Overview) • Tenderness over joint • Joint stability – passive and active • Collaterals especially UCL and IP joint sprains • Tendons • Weakness of pinch grip (Grade 2 or 3 UCL injury) • Colour and sensation status Differential Diagnosis • Degree of strain • Dislocation reduced elsewhere • Fracture • Tendon injury Investigation Refer for X-ray and reporting as appropriate: • Refer to medical practitioner for stress X-ray (under nerve block) if thumb UCL injury continued … 120 Identifier Read Code Sprain Thumb continued S522.. (Most Important is Ulna Collateral ligament sprain) Action Plan Refer all but simple injuries to a medical practitioner UCL injuries: • Grade 1: – RICE – Thumb spica/elastoplast – Physiotherapy • Grade 2: – Thumb spica splint/plaster for 4-6 weeks – Physiotherapy • Grade 3: – Refer as ligaments become degraded very quickly, making acute repair difficult – Chronic UCL injuries and large avulsion fractures not uniting, with residual instability, pain and weakness of pinch grip, need referral for surgery • Capsular MCP joint sprain (as Grade 1): – Brace/Splint 7-10 days to prevent hyperextension – Prone to recurrence • IP joint sprains: – Partial tear – buddy strap 7-10 days, physiotherapy – Volar plate – splint for 5-10 days at 10-15° flexion – Complete rupture – refer Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury • Refer all but trivial injuries • Physiotherapy (hand specialist if available) • Occupational therapy Patient Education • Continue regular analgesia e.g. paracetamol, avoid aspirin • Instruct in use of a splint see: Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Instruct in care of cast see: Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows – the longer a joint remains immobile, the greater the possibility that excess swelling may lead to decreased use of the area • Remove splint 3-4 times a day for 10 minutes and actively exercise (especially important in the elderly) – also lessens the chance that the hand’s range of movement will be permanently compromised • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) continued 121 Sprain Finger Identifier Read Codes Key Points 122 Sprain Finger S523./S5513 • The key is to maintain mobility while keeping stability, sensation and analgesia • Early mobilisation requires early review, usually at 7-10 days • These codes include: – MCP joint strains – PIP joint strains, especially volar plate tears (often missed) – DIP joint strains • Children <12 years rarely sprain ligaments (likely to fracture growth plates or suffer greenstick injury) • Elderly patients more likely to fracture than sprain • RICE therapy early • Watch tendon rupture in elderly Complications • Chronic recurrent tendonitis • Unstable joints • Boutonnière deformity (after volar plate injury – usually develops after initial injury) • Chronic mallet deformity • Chronic swelling History • Comprehensive nursing assessment • Mechanism of injury • Direct impact • Traction • Torsion forces • History of dislocation Assessment (According to Competency) • Tenderness • Swelling • Deformity • Stability • Range of movement, passive and active checking, also tendon function Differential Diagnosis • Fracture (fractures involving avulsions of <30% of joint surface from the volar plate can be treated as per sprains) • Dislocation • Tendon injuries (note FDP avulsions often missed) • Arthropathies • Neurovascular injuries Investigation Refer for X-ray and reporting as appropriate: • X-ray all but most trivial injuries Action Plan • RICE • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Immobilisation/Strapping – buddy strapping, do not strap over joints • Refer all volar plate injuries, actual or suspected, to a medical practitioner for an extension block splint • Review 7-10 days • Early mobilisation in elderly • Exercises continued … Identifier Read Codes Onward Referral Patient Education Sprain Finger continued S523./S5513 continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury • All but trivial injuries • Physiotherapy – Grades 1 and 2 • Consider home help in the elderly • Continue regular analgesia – paracetamol, avoid aspirin • Instruct in use of a splint – see Practical Techniques in Injury Management: Casts and Splints: ACC2373 • Wriggle fingers on affected limb frequently • Exercise nearby joints as instructed and comfort allows – the longer a joint remains immobile, the greater the possibility that excess swelling may lead to decreased use of the area • Return for change of strapping as instructed • Remove splint 3-4 times a day for 10 minutes and actively exercise (especially important in the elderly) – also lessens the chance that the hand’s range of movement will be permanently compromised • RICE • If the pain or swelling has not resolved significantly within 48 hours, obtain further assessment • Avoid HARMS (within the first 72 hours) 123 Sprain Hip/Thigh, Sprain Hamstring Identifier Read Codes Key Points Sprain Hip/Thigh, Sprain Hamstring S53../S535. • Children <12 years rarely sprain ligaments. Consider infection, irritable hip, slipped upper femoral epiphysis, Perthes and traction apophysitis (avulsion fractures) • Elderly patients are much more likely to fracture bones than sprain ligaments • Elderly patients are prone to suffer stiffening of their joints and need early mobilisation • Watch for tendon ruptures in older patients Complications • Chronic, recurrent injury, tendonitis • Osteoarthritis • Septic arthritis • Osteomyelitis • Pain/Loss of function if inadequately rehabilitated History • Comprehensive nursing assessment • Mechanism of injury • Site of pain Assessment (According to Competency) • Active and passive range of motion of hip joint and resisted movements • Palpate for bony and muscular tenderness • Exclude hernia • Refer to medical practitioner for examination of lower back if indicated Differential Diagnosis • Fracture/Dislocation • Infection • Tendon rupture/strain – hip flexors, hip extensors, hip rotators • Arthritis • Children – Perthes, slipped upper femoral epiphysis, septic arthritis, irritable hip, osteomyelitis • Pain radiating from lower back, sacro-illiac joint • Hernias • Greater trochanteric bursitis Investigation Refer for X-ray and reporting as appropriate: • To exclude fracture • Consider FBC, ESR, blood cultures • Consider ultrasound Action Plan • RICE in first 24-48 hours • Analgesia and/or NSAIDs by standing orders or prescription • Crutches or wheelchair if required • Early mobilisation, especially in elderly • Isometric exercise training as prevention of muscle wasting – or refer to physiotherapist continued … 124 Identifier Read Codes Onward Referral Patient Education Sprain Hip/Thigh, Sprain Hamstring continued S53../S535. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Fracture • Red Flags : children and elderly • Unstable hip joint, non-weight bearing, progressive and worsening antalgic gait • No improvement after 2 weeks • Physiotherapy rehabilitation and to monitor • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, systemic illness including fever • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 125 Sprain/Strain Quadriceps Tendon Identifier Read Code Key Points Sprain/Strain Quadriceps Tendon S533. • Children <12 years rarely sprain ligaments • In children consider irritable hip, infection, Perthes, slipped upper femoral epiphysis • Elderly patients are much more likely to fracture bones than sprain ligaments • Elderly patients are prone to suffer stiffening of their joints and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most sprains • Watch for tendon ruptures in older patients • 1 of the quadriceps muscles (rectus femoris) covers both the hip and the knee, thus it is important to consider both joints when examining Complications • Chronic, recurrent injury, tendonitis • Muscle wasting • Quadriceps haematoma • Myositis ossificans History • Comprehensive nursing assessment • Mechanism of injury • Over stretching • Direct blow – contusion • Running/Kicking – strain Assessment (According to Competency) • Pain • Function to exclude fracture • Site of tenderness • Ability to actively straight leg raise • Passive, active, resisted movements of knee joint Differential Diagnosis • Fracture • Tendon rupture • Muscle tear • Infection/Abscess • Traction apophysitis (avulsion fractures in children) • Lumbar spine strain • Sacro-illiac joint strain • Contusions/Corked thigh/haematoma • Hernias • Traumatic osteitis pubic symphysis • Children – consider Perthes, slipped upper femoral epiphysis, infection, cancer, irritable hip Investigation Refer for X-ray and reporting as appropriate: • X-ray (to exclude fracture), especially children and the elderly • Consider FBC, ESR in children • Consider ultrasound continued … 126 Identifier Read Code Action Plan Sprain/Strain Quadriceps Tendon continued S533. continued • Control of haemorrhage – RICE in first 24-48 hours • Early referral to physiotherapy • Restoration of pain-free range of motion (physiotherapy) • Functional rehabilitation (physiotherapy and education) • Graduated return to activity (education and monitoring) • NSAIDs may have a place, but may also delay healing (discuss with medical practitioner) • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Splinting or knee brace as required for pain (only for a short period, up to 1 week) • Early mobilisation, especially in elderly • Isometric exercise training as prevention of muscle wasting, especially for all knee injuries Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Fracture • Diagnosis unclear • Large haematoma • Associated knee effusion • Physiotherapy Patient Education • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, systemic illness including fever • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, obtain further assessment • Avoid HARMS (within the first 72 hours) 127 Meniscal Tear (Medial/Lateral) Identifier Read Codes Key Points Meniscal Tear (Medial/Lateral) S460./S461. • History important – especially in sports person • Exclude meniscal tear if persistent symptoms in “sprained” knee • Aspiration required if tense effusion or to exclude haemarthrosis (fracture, ruptured ACL, dislocated patella, intra-articular fracture) • Check for additional injuries to knee structures e.g. ACL • Some tears require referral and possible arthroscopy • Haemarthrosis uncommon – aspiration if tense effusion • Early rehabilitation (physiotherapy) mandatory to reduce effusion. Maximises range of motion, allowing early strengthening and proprioceptive retraining and return to work/sport • Advice to patient about avoiding re-injury and further effusion is essential • May present as chronic knee pain in older people • Lateral tears are rarer than medial and can be associated with ACL injury. Also often require more rehabilitation Complications • Wasting of quadriceps muscles, especially VMO • Long-term degenerative osteoarthritis • Other underlying abnormalities present e.g. spasticity, congenital deformities, valgus/varus deformity • Chronic pain History • Comprehensive nursing assessment • Mechanism of injury • Usually a twist injury with flexed knee with a fixed foot • Sudden onset of painful knee while running, jumping, twisting or even kneeling • Swelling usually >4 hours or next day • Degree of force • Mobility since injury • Locking/Giving way • Consistent localised pain (especially joint line) Assessment (According to Competency) Differential Diagnosis • Swelling of knee joint = effusion • Pain • Check range of motion – may have “springy” resistance to extension • Torn cruciate ligament • Torn MCLs • Osteochondral fracture • Patella dislocation/subluxation • Degenerative joint disease • Other abnormalities e.g. spasticity, congential deformities, valgus/varus deformity continued … 128 Identifier Read Codes Investigation Meniscal Tear (Medial/Lateral) continued S460./S461. continued Refer for X-ray and reporting as appropriate: • Recommended X-ray if: – Suspected fracture – Child/Adolescent – High speed injury – Loose body – Haemarthrosis present • Refer Ottawa/Pittsburgh knee rules (see Sprains/Strains Overview) Action Plan • RICE • Padded crepe bandage or tubigrip and knee brace • Gradual mobilisation • Refer to medical practitioner for aspiration if tense effusion or to exclude haemarthrosis • Crutches – see Fractures and Dislocations Overview • Passive quadriceps exercises • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Physiotherapy for muscle balance assessment and strengthening programme Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • All knee injury that is more than trivial: – Not full range of motion (active/passive) – Effusion present – Pain present – Giving way present – Locking present NB: Locked knee = either loss of end-range extension or loss of all range of motion – Loss of all active/passive range of motion, refer acutely • Physiotherapy for muscle balance assessment and strengthening programme Patient Education • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, systemic illness including fever • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 129 Sprain Collateral Ligament Knee Identifier Read Codes Key Points Sprain Collateral Ligament Knee S5400/S541. • See Sprains/Strains Overview for Pittsburgh/Ottawa knee rules for X-raying knee • RICE therapy early • Use removable splints and physiotherapy rather than casts • Children <12 years rarely sprain ligaments • Elderly patients more likely to fracture than sprain • Majority achieve functional recovery if uncomplicated • Large knee effusions can cause loss of range of motion and muscle wasting, thus early rehabilitation is essential • MCL injury much more common than lateral ligament Complications • Patello-femoral syndrome • Unstable knee • Wasting of quadriceps • Meniscal injuries • Osteoarthritis if not rehabilitated appropriately History • Comprehensive nursing assessment • Mechanism of injury – direct, indirect blow • Location of pain/tenderness • Loss of function • Valgus injury on a weight-bearing flexed knee causes stress and injury to the MCL • Varus injury on a weight-bearing flexed knee causes stress and injury to the LCL Assessment (According to Competency) Differential Diagnosis • Observe gait, swelling, range of motion Investigation Refer for X-ray and reporting as appropriate: • X-ray if swollen, possible fracture, severe trauma (see Ottawa and Pittsburgh rules) Action Plan Grades 1 and 2: • RICE • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Tubigrip and crutches. Mobilise with partial weight-bearing flexion extension only • Advise on preventing further injury, especially from weight bearing and twisting on a flexed knee (e.g. getting in and out of vehicles) Grade 3: • Refer promptly to medical practitioner • Cruciate ligament injury • Meniscal injury • Fracture • Patella subluxation/dislocation/fracture continued … 130 Identifier Read Codes Onward Referral Patient Education Sprain Collateral Ligament Knee continued S5400/S541. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Diagnosis unclear • Grades 2 and 3 • Recurrent strains • Instability • Significant trauma • Fracture • Physiotherapy – may require or benefit from hinged knee brace • Physiotherapy for range of motion and strengthening of the dynamic stabilisers of the knee • Occupational therapy • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 131 Sprain Cruciate Ligament Knee Identifier Read Code Key Points Sprain Cruciate Ligament Knee S542. • Start static muscle exercises early to prevent muscle wasting • Knee should not be immobilised for more than 2 days • Ottawa or Pittsburgh rules for X-raying knee (see Sprains/Strains Overview) • Use removable splints and physiotherapy rather than casts • Meniscal injury should be estimated • Children <12 years rarely sprain ligaments • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • RICE therapy early • Watch tendon rupture in elderly • Monitor every few days if unsure of diagnosis and refer early • 2nd fracture pathognomonic of ACL rupture • ACL ruptures associated with early haemarthrosis • PCL ruptures are extracapsular and not always associated with knee joint effusion • PCL ruptures rarely require surgical repair Complications • Patello-femoral syndrome • Unstable knee • Muscle wasting causing worsening instability • Rupture of quadriceps mechanism • Meniscal injuries • Osteoarthritis History • Comprehensive nursing assessment • Mechanism of injury: – Landing from a jump, sudden deceleration – Twisting injury on a weight-bearing flexed knee – Forced hyper-extension against resistance – Forced flexion – Pivoting on the knee • Audible pop at time of injury • Inability to weight bear • Locking, catching, instability • Unresolved previous injury: previous episodes, management and results • Loss of function e.g. knee giving way • Rapid swelling (usually in first 4 hours) implies ACL/PCL rupture or fracture • Complete tears – athletes are unable to keep playing immediately following the injury Assessment (According to Competency) • Difficult to examine with large effusion present • Bruising, abrasions, scars • Swelling, gait • Range of movement – inability to bend or flex knee 90° • Define end point and resistance • Ability to work/alternative duties continued … 132 Identifier Read Code Differential Diagnosis Sprain Cruciate Ligament Knee continued S542. continued • Collateral ligament injury • Fracture/Dislocation e.g. tibial plateau • Other cruciate: partial/complete tear • Association with meniscus/patella/fractures/articular cartilage • Rupture of quadriceps mechanism Investigation Refer for X-ray and reporting as appropriate: • X-ray – see Sprains/Strains Overview for Ottawa and Pittsburgh rules Action Plan • RICE • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Splint/Crutches • Reassess early (24/48 hours), refer if appropriate • Start static muscle exercises early to prevent muscle wasting – quadriceps • Early referral to physiotherapy for rehabilitation (preparing knee for surgery) and rehabilitation • Rehabilitation should begin on day 1 and should be a team approach (nurse, doctor, specialist and physiotherapist). Patient should be educated that rehabilitation is a long, slow process. Compliance with the rehabilitation programme is crucial for satisfactory outcome and to avoid long-term complications • The ACL has a major proprioception function. Any rehabilitation programme must include ongoing balance retraining Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Diagnosis unclear • All but trivial injuries • No improvement after 1 week • Aspiration required • Physiotherapy • Occupational therapy • Possibly podiatry Patient Education • Continue regular analgesia until pain settles – avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 133 Sprain Ankle (Lateral Ligaments) Identifier Read Code Key Points Sprain Ankle (Lateral Ligaments) S550. • See Sprains/Strains Overview for Ottawa rules for X-raying ankle injury (plus Red Flags ) • Inversion injury – exclude fracture of 5th MT • Medial ligament sprain is rarely isolated, review for other sprain or fracture • Rupture of tibio-fibular ligaments • Rupture tibialis posterior tendon especially if >45 years • Foot needs to be maintained at 90° to appose ligament ends for perfect healing • Children <12 years rarely sprain ligaments • Elderly patients more likely to fracture than sprain • RICE therapy early Complications • Instability • Swelling • Arthritis • Pain syndrome • Osteochondral defects • Capsulitis History • Comprehensive nursing assessment • Mechanism of injury: usually inversion with rotation (for lateral ligament injury) • Record whether weight bearing • Location of pain will indicate which ligament has been injured • Swelling • Pain elsewhere in the limb • Previous injury – type and residual dysfunction • Eversion injury more suggestive of medial ligament damage or fracture • Compressive type of injury suggestive of osteochondral injury Assessment (According to Competency) • Compare with uninjured ankle • Check function and ability to weight bear • Site of tenderness • Swelling and bruising • Check full length of fibula • Check 5th MT (base) • Range of movement • Range of sensation Differential Diagnosis • Fracture • Lateral/Medial ankle strain • Anterior inferior tibio-fibular ligament tear Investigation Refer for X-ray and reporting as appropriate: • X-ray – use Ottawa rules (see Sprains/Strains Overview) • Full length of fibula • Consider stress views if instability • Consider bone scan if indicated continued … 134 Identifier Read Code Action Plan Sprain Ankle (Lateral Ligaments) continued S550. continued The management of lateral ligament injuries of all 3 grades follows the same principles: • Initial management RICE/HARMS • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Functional exercise – with reference to physiotherapist • Return to activity (taping) • Grade 1: – RICE/HARMS – Education/Physiotherapy – Crepe or tubigrip strapping – Review in 1 week if no improvement Refer and discuss Grades 2 and 3 with a medical practitioner • Grade 2: – RICE/HARMS – Simple analgesia by standing orders or prescription – Consider NSAIDs – Physiotherapy – Consider cast/splint for 1 week – Review 1 week if no improvement • Grade 3: – Stabilise in cast/backslab (non-weight bearing) 7-21 days with weekly clinical review – Physiotherapy/Taping – Mobilise with partial weight bearing (at 1-3 weeks) and crutches Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work • Grades 2 and 3 sprains • Unsure of diagnosis • Physiotherapy – Grades 1 and 2 Patient Education • Continue regular analgesia until pain settles e.g. paracetamol, avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Encourage regular quadriceps exercises • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for further examination if unable to manage activities of daily living • Untoward swelling – advise patient what to expect and when to return • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 135 Sprain Metatarso-Phalangeal Joints/ Interphalangeal Joint Identifier Read Codes Key Points Sprain of Metatarso-Phalangeal Joints/Interphalangeal Joint S5512/S5513 • Includes strains of all MTP and IP joints of the foot and toes e.g. haemarthrosis of MTP joint, sesamoiditis • Good history and examination are important especially of the whole foot; MTP joint strains may reflect whole foot pathology, especially in runners • Plantar displacement best seen on lateral X-ray • If persistent pain after 7-10 days, need to re-X-ray for occult fracture • Toes must heal in normal shape to fit shoes and avoid pressure areas • Gout may be triggered by trauma, presenting 2-5 days after injury • MTP joints must heal with normal mobility to maintain normal gait Complications • Gout • Chronic metatarsalgia History • Comprehensive nursing assessment • Mechanism of injury • Twisting injury • Hyper-extension • Occupation e.g. dancer, athlete • Level of exercise Assessment (According to Competency) • Examine whole foot, especially arches, skin • Circulation/Sensation • Tendons and ligaments: passive and active range of movement • Deformity • Colour • Swelling, erythema • Point tenderness • Pain on stressing ligaments • Gait Differential Diagnosis • Fracture of MT neck with/without plantar tilt of MT head • Stress fractures of MT neck • Dislocation • Infection • Tendon rupture • Metatarsalgia due to hallux rigidus or hallux valgus • Gout • Intra-articular fracture • Plantar fasciitis • Interdigital neuroma (Morton’s neuroma) Investigation Refer for X-ray and reporting as appropriate: • X-ray toe and foot if fracture suspected continued … 136 Identifier Read Codes Action Plan Sprain of Metatarso-Phalangeal Joints/Interphalangeal Joint continued S5512/S5513 continued • RICE • Buddy strap the affected toe to the adjacent toe with gauze pads between toes • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Stout shoes • Orthotics Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to complete some work tasks with injury • Diagnosis unclear • Fracture • Displaced intra-articular fracture • Dislocation • Tendon rupture • Possible stress fractures • Physiotherapy for gait assistance and joint mobilisation if restriction present • Podiatry Patient Education • Continue regular analgesia until pain settles – avoid aspirin • Encourage frequent movement of toes on affected limb • Exercise nearby joints as instructed and comfort allows • Instruct in the use of crutches – see Fractures and Dislocations Overview • Return for change of strapping as instructed • Wear stout shoes to support toes • Need for prompt reassessment if: – Severe pain not relieved by simple analgesia or elevation of the affected limb – Severe pain disproportionate to the injury – Untoward swelling – advise patient what to expect and when to return – Unable to manage activities of daily living • RICE • If the pain or swelling has not resolved significantly within 48 hours, seek further assessment • Avoid HARMS (within the first 72 hours) 137 138 Section Five: Other Soft Tissue Injuries Overview.......................................................................................................................................................141 Wound Management..................................................................................................................................141 Anaesthesia and Analgesia........................................................................................................................142 Antibiotic Prophylaxis and Tetanus Prophylaxis..........................................................................................144 Wound Closure...........................................................................................................................................145 Patient Education.......................................................................................................................................147 Skin Tears..................................................................................................................................................148 Codes and injuries SD000 Abrasion Face....................................................................................................................150 SD20./SD30./SD602/SD60. Abrasion Shoulder/Upper Arm/Lower Arm/Knee/Leg.........................................................151 SD10. Abrasion Trunk...................................................................................................................152 7G321/S935. Abrasion Nail/Open Wound Fingernail................................................................................153 S8… Open Wound Trunk.............................................................................................................154 S82.. Open Wound Ear................................................................................................................155 S830./S8342 Open Wound Scalp/Open Wound Forehead........................................................................156 S832./S8341/S8343/S8344/S8345/S836. Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth..........................................................158 S922./S93.. Open Wound Elbow/Forearm/Wrist/Hand, Finger/Thumb...................................................159 S87../S88.. Open Wound Buttock/Ext Genitalia....................................................................................161 S9.../S90../SA10./SA2../SA3.. Open Wound Upper Limb/Shoulder/Knee, Leg/Ankle, Foot/Toe.........................................162 SE0../SE2../SE3../SE4.. Contusion (Bruise) Face, Scalp, Neck/Trunk/Upper Limb/Lower Limb.................................163 Sk0Y. Compartment Syndrome (acute).........................................................................................165 SF203 Crush Injury Upper Arm......................................................................................................166 SF22. Crush Injury Wrist or Hand..................................................................................................169 SF23./SF231 Crush Injury Finger(s)/Thumb (open and closed)................................................................172 SF322 Closed Crush Injury Foot.....................................................................................................175 139 140 Overview Wound Management The timely and appropriate management of wounds can greatly reduce subsequent morbidity. It is essential to reduce stress when dealing with paediatric wounds as cosmetic and surgical outcomes in children are directly related to the distress suffered by the child. Key Points • Facilitate healing by accurate assessment, treatment and management of all local and systemic factors during care • Restore anatomical function • Prevent infection • Attain cosmetically acceptable result History • Comprehensive nursing assessment • Mechanism of injury: – Wounding agent, crush/shear/stab – Potential contaminants and foreign bodies – note Luge injuries – Species of animal or insect if bite wound – Self-inflicted wound – Assault (possible domestic violence) • Time of injury versus time of presentation • Associated symptoms: – Pain, paraesthesia, anaesthesia, weakness, loss of function, blood loss • Tetanus immunisation status • Prior medical history: – Immunosuppression/Corticosteroid use – Heart disease requiring endocarditis prophylaxis – Previous keloid or hypertrophic scar formation – Asplenia – Bleeding disorders – Implanted prostheses Assessment (According to Competency) • • • • • • • Airways, breathing, circulation Vital signs recorded Secondary survey if required Weight for children for calculating drug dosage Pain assessment Aggravating factors Full range of motion, both active and passive, of adjacent joints if possible tendon injury 141 Wound Assessment Document: • • • • • • • • • • • • Length, width, depth Location Shape of wound Surrounding skin Amount and type of exudate Colour of wound bed, red, yellow, black, blanching, pale Direction of wound related to skin surface – perpendicular/oblique e.g. flap wound on cheek requires special consideration Vascular integrity Distal nerve and tendon function Evidence of obvious contamination – NB: Luge injuries may be contaminated with minute rubber particles which must be removed Viability of tissues Signs of infection (may include 1 or some of the following: pain, inflammation, excessive exudate, presence of pus, abnormal granulation tissue) Imaging: • Imaging is essential if there is suspicion of an associated fracture or foreign body Anaesthesia and Analgesia – According to Competency or Standing Orders Following analgesia, monitor for effectiveness, especially before starting any treatments which may be painful. Removal of wound dressings has been found to be one of the most painful experiences for patients with wounds. • Adequate pain relief is essential if wounds are to be cleaned, inspected and repaired under optimal conditions • Anaesthesia of the affected area may need to be supplemented by: – Sedation in anxious and paediatric patients • An assistant may be useful when suturing children • A variety of anaesthetic techniques are available: – Local anaesthesia – topical or by infiltration – Refer to medical staff for: » Regional » General Local Anaesthesia • Topical agents e.g. amethocaine/lignocaine/adrenaline solutions (e.g. Emla, Ametop gel) are particularly suited to use in children and provide excellent levels of local anaesthesia without discomfort • Infiltration agents – several are available: 142 agent onset of action duration of action max dose Lignocaine 1 minute 30-60 minutes 4 mg/kg Lignocaine/Adrenaline 1 minute 60-120 minutes 7 mg/kg Bupivicaine 5-10 minutes 90-180 minutes 3 mg/kg The discomfort of local anaesthetic infiltration has been shown to be minimised by: • • • • Slow infiltration (facilitated by use of small gauge needles) Infiltration into subcutaneous fat Infiltration as the needle is withdrawn Warming of anaesthetic solution to 37-40° C Side effects of local anaesthetic agents: • Allergic reactions • Systemic toxicity • Allergic reactions are very uncommon and are normally related to the preservative in the solution rather than the anaesthetic agent • Systemic toxicity is manifested by: – Tachycardia – Perioral tingling or numbness – Nausea – Vomiting – Seizures – CVS collapse It is related either to administration of an excessive amount of the agent or to its inadvertent IV injection. Management involves: • • • • Discontinuing administration Attention to airway, breathing and circulation Administration of Benzodiazepines to treat seizures Treating cardiovascular collapse with IV fluid administration and if necessary a vasopressor such as Adrenaline. NB: Adrenaline must only be administered by medical staff. Regional Anaesthesia – Only if Competent to Perform This • Digital block – anaesthetic block of fingers or toes. It is essential to deposit anaesthetic in the vicinity of both dorsal and palmar digital nerves if full anaesthesia of a digit is to be secured • Sole of the foot. Local infiltration here is particularly painful. Regional blockade of the sural and tibial nerve is much less painful to the patient and provides excellent anaesthesia • Following administration of sedation by medical staff: – Whenever conscious sedation is used, the patient should be monitored continuously. Children may take 2-3 hours to recover. Monitor: » O2 saturation » Respiratory rate » Heart rate » BP • Systemic analgesia according to competency and standing orders: – Morphine – given IV (for speed and predictability of onset). Boluses of 1-2.5 mg until pain adequately controlled. (Max dose 0.1 mg/kg in children) – orally for children (0.1 mg/kg) – Monitor vital signs following administration General Anaesthesia • Referral for GA may be appropriate for: – Young children if unco-operative, even with relatively minor wounds – Adults with more extensive wounds 143 Wound Preparation The aim of wound cleaning is to remove debris and necrotic tissue from the wound surface and minimise the risk of infection or prolonged inflammation from foreign materials. Cleaning: • N/Saline or potable water for wound cleaning in all situations • Severely contaminated wounds – aqueous Povidone-Iodine 1% can be used. Should be left in situ for 3-5 minutes then washed off with saline • Wounds should be irrigated under pressure only when there is visible suspected contamination. The ideal is 13 pSi, obtained by using a 30 ml syringe and a 20-gauge needle • If it is necessary to remove hair in the course of wound repair, it should be trimmed rather than shaved • Scrubbing of wounds may be necessary. Luge wounds impregnated with rubber (which may not be obvious) require thorough cleaning by scrubbing to avoid infection Sharp debridement – dependent on competency of nurse, or refer to medical staff: • Devitalised tissue should be carefully debrided • Irregular wound edges, other than on the face, should be trimmed Antibiotic Prophylaxis and Tetanus Prophylaxis Nurses may be responsible for all but prescribing the tetanus and antibiotics or may be able to do both – dependent on local working conditions (standing orders, policies) and competency. Tetanus vaccination schedule for acute wound management hx of vaccination time since last dose type of wound dtp/dt/ tt tet immunoglobulin 3 doses or more <5 years All No No 5-10 years Clean/Minor No No >10 years All wounds Yes No Clean/Minor Yes No Yes Yes Unknown/fewer than 3 doses Others DTP for children <8 years ADT for patients >8 years *Toxoid and TIG should be given at the same time, but into different limbs using separate syringes. Allergic reactions to tetanus toxoid are extremely rare, although local reactions are common. If the possibility has been raised, the patient can be treated with tetanus immunoglobulin if considered appropriate and they can then be referred for allergen testing to confirm or refute the possibility of allergy. Antibiotic prophylaxis has been shown to reduce wound infection rates in a number of situations: 144 • Wounds caused by a crush injury • Wounds contaminated with soil, vegetation or faeces • Late presentation (hand/foot wounds more than 8 hours after injury, other areas more than 12 hours after injury) • High-risk bite wounds see Miscellaneous: Dog Bites/Human Bites/Cat Bites TE60./U120. • Circulatory impairment – peripheral vascular disease or lymphoedema • Impaired host defence – immunosuppression, diabetes mellitus • Wounds affecting cartilage (ear/nose), tendon, bone and joint Choice of antibiotic agent: • • • • Single agent prophylaxis is preferred – encourages compliance Animal bites/faecal contamination – amoxycillin/clavulanate Puncture wounds to foot through sole of shoe – ciprofloxacin (gives cover for pseudomonas) All other wounds requiring prophylaxis – flucloxacillin/dicloxacillin/amoxycillinclavulanate/doxycycline/ metronidazole/clindamycin/ciprofloxacin (recommendations vary): – Optimal duration of therapy is unclear – 5 days is commonly recommended Wound Closure Several different techniques of wound closure are available: • • • • Tape Adhesives Staples Sutures Adhesive strips: • Adhesive strips have several advantages over suturing in the closure of certain wounds: – Simplicity of application – Reduced need for anaesthesia – Elimination of need for suture removal – Lower infection rate than sutured wounds – Do not use on areas where there is movement or tension across the wound – Allow for sufficient space between adhesive strips to allow drainage and reduce the risk of infection – Apply horizontally across the wound and do not criss-cross – Application of tinct benzoin can improve adhesion – May not stay in situ for long on children • Wounds suitable for adhesive strips: – Superficial straight lacerations under little tension – Lacerations and bite wounds with high potential for infection – Skin tears – With caution in patients with very thin skin which would be torn by sutures – Tapes may also be used to support lacerations after suture removal to minimise widening of the scar Tissue adhesives (glues): • Tissue adhesives give a cosmetic result equal to suturing under certain circumstances. Characteristics of suitable wounds: – Lacerations with sharp edges and under little tension where no deep sutures are required – Lacerations 5 cm or less in length • If used on the face, steps must be taken to prevent the adhesive accidentally reaching the eye • Adhesives are not suitable for: – Lacerations subject to deforming stresses such as near joints – Lacerations that are actively bleeding – Lacerations of mucosal surfaces Application of tissue adhesives: • • • • After wound cleaning, oppose edges of wound and apply tissue adhesive to wound surface Do not allow glue to enter the body where it will act as a non-absorbable foreign body Do not apply too thickly, as heat is generated on application and can cause discomfort Hold edges together for 1 minute after applying glue 145 Staples and sutures: • May be applied by nurse according to individual competency and local guidelines Staples: • Stapling gives as good a cosmetic result as suture closure and is very much faster. Cost of disposable stapling devices may be offset by time saved in wound closure and by the reduced need for wound-closure instruments • Wounds suitable for stapling: – Linear lacerations of the scalp, trunk and extremities – Staples should be avoided for facial and hand lacerations Sutures: • • • • Interrupted sutures most commonly used Monofilament sutures are preferred Silk/Absorbable sutures may be more comfortable in the mouth Use absorbable sutures for deep tissue planes Guide to appropriate suture size and time for removal according to location of wound: body region suture size time for removal Scalp 3/0-4/0 7 days Face 6/0 5 days Trunk 3/0-4/0 Front 7 days Back 10 days Arm/Leg 4/0 10 days Hand/Foot 4/0-5/0 12 days • Add 2-3 days for wounds crossing extensor surfaces and subtract 2-3 days in young children Dressings: • • • • • Sutured wounds should be kept dry and covered for protection from damage and infection only All other wounds require a moist, clean, warm environment Wounds should not be disturbed unnecessarily as this disrupts the healing tissue Wound dressings should extend 3-4 cm beyond the wound edge Adhesion can be helped by use of commercial products which reduce skin oil or by application of tinct benzoin • Choice of wound dressing should always be based on assessment of the wound and required outcomes • Do not occlude clinically infected wounds • Common groups of wound dressing: 1. Film dressings – as a secondary dressing or on dry or very lightly exudating wounds 2. Retention dressings – often used now for clean superficial grazes and lacerations, directly onto the wound. Left in place for 7-10 days then removed following application of oil for 4 hours or more. Patients must be given a patient information leaflet and be able to shower regularly to remove exudate 3. Silicone non-adherent dressings – always preferable to impregnated gauze dressings and have been shown to be far less painful, especially on removal of dressings. This is particularly important with children 4. Hydrocolloids – useful for superficial burns and any light to moderately exudating wound. Have limited fluid-holding capacity. Can stay in situ for 7 days. Shower proof 5. Hydrogels – maintain moist environment. Facilitate autolytic debridement. Use with caution if at all in infected wounds. Require a secondary dressing. Should not be left for longer than 3 days 6. Hydrofibre – autolytic properties and will absorb excess exudate without causing maceration. Available as flat or rope dressings. Do not use on minimally oozing wounds 146 7. Alginates – highly absorbent, with haemostatic properties. Available as rope or flat dressings. Biodegradable if small quantities left in the wound. Can cause maceration if allowed to overlap the wound too far. Must not be used on low-moderately exudating wounds as will adhere to the wound bed 8. Foams – the majority are for highly exudating wounds. Follow manufacturer’s instructions 9. Silver-based wound dressings (excluding colloidal silver) – excellent for use in contaminated wounds or ones prone to infection. Several available, follow manufacturer’s instructions 10. Cadexomer iodine – as above, but also useful for desloughing wounds. Should be left in situ for 3 days. Not suitable for large areas. Contraindicated in patients with a history of thyroid problems 11. Manuka honey – patients often ask to use this. It is a useful anti-microbial. Ensure that you obtain 12+ or more or use honey manufactured for the use of wound care from a reputable supplier. May sting on application. Do not apply where there is a history of allergy to honey or honey based products. Patient Education Care of Stitches The first 24 hours (uncomplicated wounds): • Keep wound clean and dry • If during the first 24 hours the wound bleeds enough to soak through the bandage, remove it, and with a clean cloth firmly apply pressure for 15 minutes; when bleeding stops, reapply a clean bandage. If the bleeding does not stop or soaks through a new bandage, seek medical care promptly. (Patients may choose to seek medical care for initial bleeding) • Avoid activities that place stress or tension on the wound • Avoid alcohol and aspirin as these increase the chance of bruising and/or bleeding around the wound • It is normal to see a slight yellow discharge from the wound as it heals After 24 hours: • Gently wash the wound in warm water each day using clean gauze or cloth (not cotton wool) • Do not soak the wound in water e.g. bathing, swimming or washing the dishes • Change the bandage each day. Launder the used bandage, soak any blood-stained material in cold water prior to washing • Stitches in the mouth – use salted water as a mouthwash after every meal (1 teaspoon salt dissolved in a glass of cool boiled water) • Stitches in the scalp – use a small amount of shampoo to wash gently around the wound Infection: • Seek prompt medical attention for signs or symptoms of infection: – Local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling or an overall feeling of illness including fever Removal: • • • • Usually stitches stay in place for 5-10 days, depending on their site Do not attempt to remove the stitches yourself Return to your health care provider on the day they advise Stitches in the mouth are usually made of special thread that dissolves in about 7-10 days. It is normal for bits to break off as they dissolve – do not rub the stitches with your tongue as this may re-open the wound Seek help: • • • • Urgently for any signs of infection Any bleeding from the wound that does not stop with firm pressure for 15 minutes Any pain disproportionate to the size of the wound Any problems with maintaining activities of daily living 147 Skin Tears Identifier Read Code Key Points Skin Tears A skin tear is described as: “traumatic injury occurring on the extremities of older adults as a result of shearing and friction forces, which separates the epidermis from the dermis” (Payne & Martin 1990) payne-martin classification of skin tears Category I Ability to proximate the wound borders, no tissue loss Type A Linear Type B Flap Category II Varying amount of tissue loss Type A Scant tissue loss <25% Type B Moderate tissue loss >25% Category III Complete tissue loss Complications • Infection • Development of chronic wound, especially on the lower leg in elderly patients History • Comprehensive nursing assessment • Co-morbidities • Medications • Tetanus immunisation status Assessment (According to Competency) • Assessment of shape, size and position of wound. Classify depth according to Payne-Martin classification • Position in relation to underlying structures • Presence of debris or dead tissue for removal • Appearance of limb and surrounding skin Investigation Action Plan • Wound culture if late presentation and signs of clinical infection present • Once the bleeding has stopped, clean the wound thoroughly and gently with warm normal saline, take care not to damage the skin flap further • Remove any debris and blood clots • Full-thickness skin tears with a flap (Category II). Puncture the skin flap with a sterile sharp needle to create holes for drainage of fluid • Trim off any non-viable tissue and tidy wound edges • Lay flap gently over the wound bed. Avoid stretching even if it means the edges do not unite • Secure with adhesive strips • Apply an alginate if the wound is bleeding, otherwise a foam provides protection from further injury and absorption of exudate. Do not use adhesive tapes on paper-thin skin • Mark the dressing with arrows to signify which way it should be removed at next dressing change • Apply a firm bandage – if the wound is on the lower limb, it is preferable to do this from toe to knee to prevent oedema developing above or below the bandage. Do not apply compression bandages without a full assessment including ankle brachial index reading • Leave in situ for 5-7 days unless there is excess exudate or signs of clinical infection continued … 148 Identifier Read Code Onward Referral Skin Tears continued Refer on to medical staff or specialist leg ulcer clinics: • If infection develops • For further debridement if nurse not competent to carry this out • If wound is not decreasing in size or improving at assessment in week 4 149 Abrasion Face Identifier Read Codes Key Points 150 Abrasion Face SD000 • Exclude serious underlying injury • Clean wounds meticulously to avoid subsequent tattooing by retained foreign bodies • Clinical examination of facial skeleton is superior to X-ray in detecting fractures • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury Complications • Infection • Scarring • Tattooing • Missed underlying injury History • Comprehensive nursing assessment • If associated head injury: – LOC/Duration – Clinical course following injury • Symptoms suggestive of blow-out fracture of orbit: – Diplopia/Pain on upward or lateral gaze • Symptoms suggestive of mandibular/maxillary fracture: – Malocclusion/Pain on biting • Tetanus immunisation status Assessment (According to Competency) • Initial focus on airway, breathing and circulation followed by neurological examination if associated head injury • Check stability of maxilla if possible mid-facial fractures • Wound assessment to include area, depth, shape, location of wounds • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Periorbital injuries • Full eye examination, including visual acuity Differential Diagnosis Investigation • Underlying facial fractures • Ocular trauma Action Plan • Analgesia by standing orders or prescription to allow thorough cleaning: – Local anaesthetic if small area – For larger areas, nerve blocks, Entonox may be appropriate • Clean with warm N/Saline • Remove all foreign material (use scrubbing brush/sterile soft toothbrush if necessary) • Dress with hydrocolloid/Tegaderm or leave open • Use of topical antibiotics creams is contraindicated unless for specific bacteria, as they result in resistance developing • Inspect at 5 days unless signs of infection develop earlier • Provide tetanus prophylaxis (see Wound Management Overview) as necessary Patient Education • Suspected mandibular/maxillary fractures – according to local practice • Suspected periorbital injuries • If patient’s age or extent of abrasions precludes adequate cleaning • X-ray facial bones if possible fractures • Wound culture if late presentation and wound infection apparent Abrasion Shoulder/Upper Arm/Lower Arm/Knee/Leg Identifier Read Codes Key Points Abrasion Shoulder/Upper Arm/Lower Arm/Knee/Leg SD20./SD30./SD602/SD60. • Exclude serious underlying injury • Clean wounds thoroughly to avoid subsequent tattooing by retained foreign bodies • Soft tissue injury alone or in combination with an underlying fracture may cause a compartment syndrome • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury Complications • Infection • Scarring • Tattooing • Ischaemic contractures from compartment syndromes History • Comprehensive nursing assessment • Symptoms of compartment syndrome: – Disproportionately severe, poorly localised pain – Severe swelling – Hyperaesthesia/Paraesthesia in distribution of nerves crossing compartment • Tetanus immunisation status Assessment (According to Competency) • Deformity/Limitation of movement of limb suggesting underlying fracture, dislocation or closed tendon injury • Wound assessment to include area, depth, shape, location of wounds • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Signs of compartment syndrome: – Pain on passive stretching or active flexion of affected muscle groups – Distal sensory abnormalities • NB: Normal distal pulses, skin colour and capillary return do not exclude compartment syndrome Differential Diagnosis Investigation • Underlying fracture • Compartment syndrome Action Plan • Analgesia by standing orders or prescription to allow thorough cleaning: – Local anaesthetic if small area – For larger, Entonox may be appropriate or refer to medical practitioner • Clean with warm N/Saline • Remove all foreign material (use scrubbing brush if necessary) • Dress with silicone non-adherent dressings or retention dressings • Inspect at 2 days unless signs of infection develop earlier. Redress with silicone non-adherent/hydrocolloid. If no problems, leave retention dressing in situ, provide patient with information on correct use, showering etc • Provide tetanus prophylaxis (see Wound Management Overview) Onward Referral • Patient’s age or extent of abrasions precludes adequate cleaning • Underlying fracture/dislocation or potential/actual compartment syndrome • X-ray if possible underlying fracture/dislocation – according to standing orders • Wound culture if late presentation and wound infection apparent 151 Abrasion Trunk Identifier Read Code Key Points 152 Abrasion Trunk SD10. • Exclude serious underlying injury. NB: In children the highly compliant rib cage may allow serious intra-thoracic or abdominal injury to occur with relatively minor evidence of injury externally • Clean wounds thoroughly to avoid subsequent tattooing by retained foreign bodies • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury Complications • Infection • Scarring • Tattooing • Co-existent intra-thoracic and abdominal injuries History • Comprehensive nursing assessment • Mechanism of injury • Tetanus immunisation status Assessment (According to Competency) • Initial assessment of airway, breathing, circulation and neurological state • Secondary survey of chest and abdomen if appropriate • Wound assessment to include area, depth, shape, location of wounds • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies Differential Diagnosis Investigation • Underlying fracture • Intra-thoracic/intra-abdominal injury Action Plan • Analgesia by standing orders or prescription to allow thorough cleaning: – Local anaesthetic if small area – For larger areas, Entonox may be appropriate • Clean with warm N/Saline • Remove all foreign material (use scrubbing brush if necessary) • Dress with silicone non-adherent or retention dressing • Inspect at 2 days unless signs of infection develop earlier • If retention dressing in situ, and no problems, leave • Redress with silicone non-adherent/hydrocolloid or retention dressing • Provide tetanus prophylaxis (see Wound Management Overview) Onward Referral • Evidence of actual or potential internal injury • Patient’s age or extent of abrasions precludes adequate cleaning • Patient requires off work certificate Patient Education • If signs of infection – increased ooze, pain or inflammation contact medical practitioner or nurse without delay • Take analgesia as required and as prescribed • Keep wound dry until staff say you may have a shower • Ensure you eat a good diet with all the food groups in it • Protect area from sunburn for at least 6 months • Use of vitamin A ointment/cream will help healing • CXR and ECG if significant chest trauma • Urinalysis if significant abdominal trauma • Wound culture if late presentation and wound infection apparent Abrasion Nail/Open Wound Fingernail Identifier Read Code Key Points Abrasion of Nail/Open Wound Fingernail 7G321/S935. • Inadequate repair of damage to nail bed or matrix may lead to long-term nail deformity • Subsequent revision surgery is disappointing • Associated mallet finger deformity in children is an epiphyseal injury requiring reduction and possible internal fixation Complications • Nail deformity • Non-adherence of new nail • Persistent mallet finger • Osteomyelitis History • Comprehensive nursing assessment • Mechanism of injury • Tetanus immunisation status Assessment (According to Competency) • If nail remains attached and nail bed/matrix laceration apparent or >50% subungal haematoma present – remove nail to allow full assessment and appropriate treatment • Assess for: – Nail bed/matrix laceration or tissue loss – Exposed bone/compound fracture – Associated mallet finger deformity – Late presentation signs of infection Investigation • X-ray if mechanism of injury/clinical examination suggests fracture or if mallet finger deformity • Wound culture if late presentation and signs of infection present Action Plan • Provide analgesia by standing orders or prescription with digital nerve block (never with adrenaline) • Remove nail if remains attached • Clean • Suture nail bed laceration with 6/0 absorbable (preferable) suture • Trim sides of nail and replace to prevent formation of adhesions within nail fold. NB: Also greatly reduces pain of dressing changes • If nail unavailable, use sterile Silastic sheet or part of suture packet • Dress with Silicone N-A to reduce adhesion of wound dressing • Provide tetanus prophylaxis (see Wound Management Overview) Onward Referral • Complex or extensive nail bed laceration • Nail matrix laceration • Nurse unable to perform above treatments when appropriate • Partial nail bed avulsion – refer with (appropriately chilled) avulsed tissue if possible • Mallet finger deformity in adults – refer if >25% of articular surface of distal phalanx is involved • All mallet finger deformities in children • Unstable distal phalanx fracture (unusual) • Inadvertent ring block with adrenaline – refer urgently 153 Open Wound Trunk (see also Abrasion Trunk SD10.) Identifier Read Code Key Points 154 Open Wound Trunk (see also Abrasion Trunk SD10.) S8… • History of injury and events following is critical • If consciousness level impaired, never attribute to alcohol/drugs even if such ingestions are known to have occurred • Seemingly trivial penetrating wounds of the abdomen may also involve intra-thoracic structures and vice versa Complications • Infection • Co-existent intra-thoracic and abdominal injuries • Scarring • Tattooing • Pneumo/Haemothorax – other intra-thoracic/abdominal organ damage History • Comprehensive nursing assessment • Tetanus immunisation status • Clinical course following injury • Associated symptoms/injuries • Medication, especially warfarin • History from a witness Assessment (According to Competency) • Vital signs • Examination of chest and abdomen to exclude associated injuries • Wound assessment to include length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies Investigation • CXR and ECG if significant chest trauma • Urinalysis if significant abdominal trauma • Wound culture if late presentation and wound infection apparent • Soft tissue X-ray if possible retained foreign body Action Plan • Refer to medical staff and complete treatment accordingly and dependent on competency • Clean wound and remove devitalised tissue • Suture/Staple/Glue skin (see Wound Management Overview) • Provide tetanus prophylaxis (see Wound Management Overview) Onward Referral • All patients Open Wound Ear Identifier Read Code Key Points Open Wound Ear S82.. • Exclude associated head injury • Auricular haematoma/tympanic membrane perforations (from slapping) may represent non-accidental injury • Minimal debridement of lacerations to avoid distortion of cartilage • Lacerations involving auricular cartilage merit antibiotic prophylaxis • Acute vertigo/deafness implies inner/middle ear damage • Avulsions – if avulsed tissue available, transfer with patient to plastic surgeon Complications • Chronic tympanic membrane perforations • Cosmetic deformity • External auditory canal stenosis • Auricular cartilage necrosis secondary to infection • Auricular cartilage overgrowth secondary to auricular haematoma History • Comprehensive nursing assessment • Mechanism of injury • If associated head injury: – LOC/Duration – Clinical course following injury • Acute vertigo/deafness • Tetanus immunisation status Assessment (According to Competency) • Wound assessment to include length, depth, shape, location of wound • Evidence of retained foreign body • Extent of contamination/devitalised tissue/cartilage involvement • Tympanic membrane/external auditory canal trauma • Check for hearing loss, test with tuning fork Investigation Action Plan • Audiogram if hearing impaired Onward Referral • Full-thickness skin loss +/– perichondral loss • Requires suturing • Partial/Complete avulsions • Auricular haematoma • Acute vertigo/deafness • Suspected perforation • Laceration: – Local anaesthesia with possible field block around base of ear, no adrenaline – Clean wounds – Minimal debridement – Well padded and shaped pressure dressing to reduce risk of auricular haematoma • Tympanic membrane perforation – see Miscellaneous: Tympanic Membrane Perforation FS42 155 Open Wound Scalp/Open Wound Forehead (see also Abrasion Face SD000) Identifier Read Codes Key Points Open Wound Scalp/Open Wound Forehead (see also Abrasion Face SD000) S830./S8342 • Assume cervical spine injury until such injury can be confidently excluded • History of injury and events following is critical • If consciousness level impaired, never attribute to alcohol/drugs even if such ingestions are known to have occurred • Fatal air embolism may occur through apparently trivial wounds of the neck which involve the great veins Complications • Infection • Cosmetic deformity • Associated head/cervical spine injury • Concussion • Skull fracture • Intracranial haemorrhage • Dural tear with CSF leak • Scarring • Tattooing History • Comprehensive nursing assessment • Mechanism of injury • LOC/Duration • Medication, especially warfarin • History from a witness • Tetanus immunisation status Assessment (According to Competency) • Initial focus on airway, breathing and circulation followed by neurological examination if head injury: – Pupils – Glasgow Coma Scale – Cranial nerves – Focal neurological signs in limbs • Assess cervical spine: – Tenderness – Steps/Deformity – Crepitus – Maintain protective measures until injury excluded • Wound assessment to include length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies Investigation • Wound culture if late presentation and wound infection apparent continued … 156 Identifier Read Codes Action Plan Onward Referral Open Wound Scalp/Open Wound Forehead (see also Abrasion Face SD000) continued S830./S8342 continued • Cervical spine protection until injury excluded • Except superficial wounds, refer to medical staff, then complete treatment according to competency • Clean wound (N/Saline) and remove devitalised tissue • Suture/Staple/Glue skin (see Wound Management Overview) • Forehead laceration – transverse wrinkles of forehead act as landmarks for accurate apposition of skin edges. Young patients can raise eyebrows to create wrinkles • Provide tetanus prophylaxis (see Wound Management Overview) • In penetrating neck trauma, do not allow patient to sit/stand until airtight dressing covering wound to prevent air embolism • All patients except very superficial abrasions 157 Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth Identifier Read Codes Key Points • For ears refer Open Wound Ear S82.. • Aim to repair wounds with optimal recovery of function and restoration of appearance • When closing wounds, use key sutures first to approximate landmarks • Never shave eyebrows – regrowth is unpredictable • Bite wounds to the face should be closed after thorough cleaning and debridement Complications • Nerve, vessel, muscle, eye injury • Facial fracture • Infection – potentially fatal if mid-facial and leads to cavernous sinus thrombosis • Cosmetic deformity • Facial palsy • Epiphora/Corneal exposure if tissue loss/contracture of scar of eyelids • Salivary fistula • Associated head/cervical spine injury History • Comprehensive nursing assessment • LOC/Duration • Clinical course following injury • Tetanus immunisation status • Symptoms suggestive of blow-out fracture of orbit: – Diplopia/Pain on upward or lateral gaze • Symptoms suggestive of mandibular/maxillary fracture: – Malocclusion/pain on biting Assessment (According to Competency) • Initial focus on airway, breathing and circulation followed by neurological examination if associated head injury • Check stability of maxilla if possible mid-facial fractures • Wound assessment to include length, depth, shape, location of wound and check for intra-oral involvement • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Periorbital injuries: – Full eye examination including visual acuity. Assess integrity of canthal ligaments/lacrimal apparatus • Cheek injuries – between tragus of ear and mid-pupillary line: – Check facial nerve function and look for evidence of parotid duct damage Investigation Action Plan • X-ray facial bones if possible fracture or if possible retained foreign body Onward Referral 158 Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth S832./S8341/S8343/S8344/S8345/S836. • Refer to medical staff then treat according to competency • Clean wound and remove devitalised tissue • Align landmarks • Suture/Glue/Adhesive strips to skin • Tetanus prophylaxis (see Wound Management Overview) • All patients Open Wound Elbow/Forearm/Wrist/Hand, Finger/Thumb Identifier Read Codes Key Points Open Wound Elbow/Forearm/Wrist/Hand, Finger/Thumb S922./S93.. • Remove rings on affected limb • Thorough initial examination will delineate full extent of injuries. This allows early definitive treatment and minimises morbidity • Tendon sheath, web space and palmar space infection require urgent hospital treatment • High-pressure injection injuries may present with minor signs and symptoms but over a few hours may cause irreversible ischaemic injury unless decompressed • Punch injuries (lacerations from opponent’s teeth over MC heads) are at very high risk of infection • Physiotherapy may speed recovery Complications • Infection • Scarring • Missed neurological/tendon injury • Stiffness History • Comprehensive nursing assessment • Mechanism of injury • Posture of hand at time of injury • Hand dominance • Tetanus immunisation status continued … 159 Identifier Open Wound Elbow/Forearm/Wrist/Hand, Finger/Thumb Read Codes Assessment (According to Competency) S922./S93.. continued Investigation Action Plan Onward Referral 160 continued Assess neurological function: • Position at rest • Vascular: – Colour/Warmth – Pulses – Capillary refill • Neurological: – Motor: – Ulnar nerve – finger ab/adduction – Radial nerve – wrist extension – Median nerve – function of abductor pollicis brevis/thumb opposition to fingers • Sensory: – Ulnar nerve – tip of little finger – Radial nerve – dorsal 1st web space – Median nerve – tip of index finger – Digital nerves – 2-point discrimination on ulnar/radial borders of all finger pulps • Bone and joint: – Deformity – Local tenderness – Pain with axial compression – Joint range of motion • Musculotendinous: – Function of each muscle-tendon group – Strength against resistance – Pain with motion • Explore wound with hand/finger in position in which injury occurred then through full range of active and passive movements to maximise chance of identifying divided/partially divided structures • Wound assessment to include length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • If presentation is delayed by more than a few hours, exclude infection: – Tendon sheath infection causes tenderness along tendon affected, symmetric swelling of finger, pain on passive extension and the affected finger is held flexed – Deep fascial space infections may present with swelling over the dorsum or palmar aspect of the hand or over the thenar eminence. Passive movement of adjacent digits causes pain • Remove rings if severe finger injuries • Wound culture if late presentation and signs of infection apparent • Refer to medical staff then treat according to competency • Clean wounds • Debride as necessary • Adhesive strips for hands if appropriate • Non-adherent dressing • Tetanus prophylaxis (see Wound Management Overview) • Physiotherapy if problems with mobility apparent or anticipated • All patients Open Wound Buttock/Ext Genitalia Identifier Read Code Key Points Open Wound Buttock/Ext Genitalia S87../S88.. • Refer all cases to medical practitioner after initial assessment or treatment • Anogenital trauma in children and adults may represent sexual abuse/ assault • If assault/possible abuse refer to, or discuss with, appropriate agency prior to examination, other than exclusion of life-threatening injury. Particularly for children, it is preferable that only 1 examination is done • If forensic examination required, referral to appropriately trained practitioners and use of Police examination kit required • Ensure victims of sexual assault are going to a place of safety with appropriate follow-up • Consider trauma to rectum/vagina/urethra/testes even in apparently superficial wounds • Obtain patient consent and assistance of a chaperone before conducting examination • Antibiotic prophylaxis (see Wound Management Overview) for perineal wounds Complications • Infection • Scarring • Secondary to injury to rectum/anal canal/genito-urinary system • Psychological damage • Tetanus immunisation status History • Comprehensive nursing assessment • Mechanism of injury – if paediatric patient, document child’s account verbatim as well as that of caregiver • Age • Blood loss PR/PV/PU • Features suggestive of child abuse Assessment (According to Competency) • Wound assessment to include length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • If assault possible/confirmed, refer to appropriate agency Differential Diagnosis • Bowel injury • Genito-urinary tract injury • Sciatic nerve injury Investigation Action Plan • Urinalysis for occult haematuria Onward Referral • Refer to medical practitioner and complete treatment according to competency • Analgesia/Local anaesthesia • Clean wounds with N/Saline and debride as necessary • Suture – absorbable suture to subcutaneous layers if wound gaping • Monofilament suture to skin • Apply occlusive dressing if possible, otherwise encourage washing BD • Tetanus prophylaxis (see Wound Management Overview) • Antibiotic prophylaxis (see Wound Management Overview) for perineal wounds • Review/Redress wounds at 48 hours • All patients • If possible child sexual abuse • Appropriate local agencies if sexual assault 161 Open Wound Upper Limb/Shoulder, Knee/Leg/Ankle, Foot/Toe Identifier Read Code Key Points 162 Open Wound Upper Limb/Shoulder, Knee/Leg/Ankle, Foot/Toe S9.../S90../SA10./SA2../SA3.. • Exclude serious underlying injury including significant haemorrhage • Assess distal neurovascular and musculotendinous function • Soft tissue injury alone or in combination with an underlying fracture may cause a compartment syndrome • Forefoot lacerations and puncture wounds are prone to infection. Pseudomonas common infecting organism Complications • Infection • Scarring • Missed neurovascular injury • Ischaemic contracture secondary to compartment syndrome History • Comprehensive nursing assessment • Mechanism of injury • Tetanus immunisation status • Symptom of compartment syndrome: – Disproportionately severe, poorly localised pain • Hyperaesthesia/Paraesthesia in distribution of nerves crossing compartment Assessment (According to Competency) • Wound assessment to include length, depth, shape and location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Deformity/Limitation of movement of limb suggesting underlying fracture, dislocation or closed tendon injury • Signs of compartment syndrome: – Disproportionate pain increasing in severity – Pain on passive stretching or active flexion of affected muscle groups – Distal sensory abnormalities – Severe swelling Investigation • X-ray if possible underlying fracture/dislocation • Consider wound culture if late presentation and wound infection apparent Action Plan • Refer to medical staff and complete treatment according to competency • Local anaesthesia – get analgesia prescribed as necessary • Clean wounds and debride as necessary • Apply non-adherent dressing • Tetanus prophylaxis (see Wound Management Overview) • Review/Redress wounds at 48 hours Onward Referral • All wounds Contusion (Bruise) Face, Scalp, Neck/Trunk/Upper Limb/ Lower Limb Identifier Read Codes Key Points Contusion (Bruise) Face, Scalp, Neck/Trunk/Upper Limb/ Lower Limb SE0../SE2../SE3../SE4.. • Assessment for compartment syndrome risk in limbs. Most sensitive indicator is severe pain/disproportionate pain for injury • All urethral injuries should be referred. Do not catheterise. Always consider urethral injury if perineal bruising • Always ask if history of bleeding disorders or concurrent anticoagulant use • Aspiration of haematoma is discouraged Complications • Compartment syndrome/ischaemic contracture(s) if not recognised • Excessive bleeding and haematoma formation • Calcification of haematoma in muscle belly (myosotis ossificans) • Infection • Risk of avascular/septic necrosis of nasal and aural cartilage • Chronic pain History • Comprehensive nursing assessment • Mechanism of injury: – Fall – Direct blow (with implement or fist) – Vehicular/Cycle injury • Location of pain and severity • Anticoagulants (especially warfarin, aspirin) or bleeding disorders Assessment (According to Competency) • Initial focus on airway, breathing, circulation and neurological state • Assess for associated injuries • Palpate bony landmarks and assess function to exclude fracture • Assess size, site of haematoma • Assess severity of swelling in limbs • Presence of bruising in perineum +/– blood at external urethral meatus suggests urethral injury. Assess and swab any discharge • If sexual assault, refer to medical practitioner. Assess and undertake domestic violence screening and refer to other agencies as indicated by outcome of screening i.e. Police, social work, etc • Examine nasal septum in all nasal injuries to exclude haematoma • Examine ears for aural haematoma • Muscle compartment contusion • Circulation • Haematuria in back injury or multi-trauma • Nerve injury Differential Diagnosis • Fracture • Compartment syndrome present or risk • Impaired circulation • Abrasion • Neurovascular injury continued … 163 Identifier Read Codes Investigation 164 Contusion (Bruise) Face, Scalp, Neck/Trunk/Upper Limb/ Lower Limb continued SE0../SE2../SE3../SE4.. continued • Urinalysis if back or trunk injury or multi-trauma • Refer for X-ray and reporting as appropriate (to exclude fracture in specific areas) • Referral to medical practitioner for consideration of: – Coagulation studies if on anticoagulants or history of bleeding disorder Action Plan • Resuscitation as necessary • Assess and record vital signs – continue at regular intervals according to condition • Ice packs applied to area for 20 minutes every 2-3 hours for first 24 hours to reduce pain and swelling • Complete pain assessment and provide adequate pain relief by standing orders or prescription (avoid aspirin) • Rest/Elevate (in sling if forearm or hand compression) • Reassess next day if significant haematoma forming or patient on anticoagulants Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Aural haematoma • Nasal septal haematoma/dislocation • Significant genital haematoma or urethral injury • Presence or significant risk of compartment syndrome • Alleged or suspected sexual abuse – refer to medical practitioner • Significant haematoma when on anticoagulants or has bleeding disorder • Haematuria • Suspicion of compartment syndrome • Significant haematoma of any large muscle group e.g. quadriceps • Neurovascular injury • Physiotherapy to optimise joint function if required • Home help for elderly or disabled may be required • To community services for ADL Patient Education • NSAIDs can be useful, as long as there is no significant history of asthma, when used concurrently with other simple analgesia (such as paracetamol and physiotherapy) • RICE • Avoid HARMS (within the first 72 hours) This advice does not apply to neck and back injuries Need for prompt reassessment if: • Patient taking anticoagulants • Severe pain not relieved by simple analgesia or elevation of the affected limb • Severe pain disproportionate to the injury • Changes in colour or sensation peripheral to the injury • Untoward swelling – advise patient what to expect and when to return • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Unable to manage daily living or work Compartment Syndrome (Acute) Identifier Read Code Key Points Patient Education Compartment Syndrome (acute) Sk0y. • Acute compartment syndrome can occur to a limb following fractures or soft tissue injuries; it requires prompt diagnosis and urgent treatment. Following injury, increased interstitial pressure can lead to obstruction of the microcirculation with resulting tissue necrosis. The commonest site to be affected is the anterior compartment of the lower leg • Clinical features include: – Progressive swelling of limb – Persistent pain (greater than one would normally expect for a given injury) – Erythema – Increased tissue tension – Extreme pain on passive stretch of involved muscles – Progressive loss of sensory and motor function – The loss of capillary return and peripheral pulses are unreliable indicators of the severity of the condition • If suspected, urgent medical referral is required for immediate decompression, usually by fasciotomy • In order to support a decision to perform fasciotomy, confirmation of the increase in compartment pressures – usually N20 mmHg – from any number of commercially available dedicated apparatus or kits is required • Hyperbaric therapy may be useful and should realistically be considered where this treatment modality is available. This acts on the principle that oedema may be reduced through oxygen-induced vasoconstriction (Wattel et al 1998) Need for prompt reassessment if: • Severe pain not relieved by simple analgesia or elevation of the affected limb • Severe pain disproportionate to the injury • Changes in colour or sensation peripheral to the injury • Untoward swelling – advise patient what to expect and when to return 165 Crush Injury Upper Arm Identifier Read Code Key Points Crush Injury Upper Arm SF203 • Careful assessment and monitoring to detect compartment syndrome early; if suspicious, seek urgent medical advice. Compartment pressure studies are likely to be required • Meticulous wound management • Assess and document neurovascular status Complications • Compartment syndrome with ischaemic contractures if unrecognised • Nerve injury • Infection History • Comprehensive nursing assessment • Mechanism of injury: – Industrial machinery (rollers) – Vehicular accident • Associated injuries • Tetanus immunisation status • Current medications, especially anticoagulants and allergies • Co-morbidities, especially diabetes and immunocompromise Assessment (According to Competency) • Assess each muscle compartment for swelling and impending compartment syndrome • Skin laceration/abrasion • Assess for presence of foreign bodies • Neurovascular impairment • Crepitus suggesting bony injury Differential Diagnosis • Laceration • Fracture • Nerve injury • Major vessel injury Investigation Refer for X-ray and reporting as appropriate: • X-ray may be required to exclude fracture • Hand-held Doppler ultrasound can often prove useful when palpable pulses (brachial, radial and ulna) are not immediately obvious and clinical examination is suggestive of compartment affectation continued … 166 Identifier Read Code Action Plan Onward Referral Crush Injury Upper Arm continued SF203 continued • Treat associated injuries as indicated • Analgesia as required by prescription or standing orders • Tetanus prophylaxis (see Wound Management Overview) Open wound: • Document neurovascular status • Immediate medical referral if suspicion of compartment syndrome • Either refer to medical practitioner or, according to competency, infiltrate local anaesthetic for irrigation and meticulous debridement • Close wounds if appropriate or refer to medical practitioner for suturing • Simple dressing to keep covered and protected • Rest in broad arm sling • Review wounds 24-48 hours • Antibiotic prophylaxis if high-risk wound (see Wound Management Overview) Closed injury: • Document neurovascular status • Immediate medical referral if suspicion of compartment syndrome • Rest in broad arm sling • Review as indicated • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Assessment, investigations or treatment required if outside area of competency • Signs/Symptoms suggestive of (or significant risk of) compartment syndrome: – Severe pain, especially on passive extension (earliest and most sensitive sign) – Severe swelling – Neurological impairment – Diminished pulses or perfusion (late sign) • Extensive wounds requiring GA for debridement • Nerve/Tendon injury • Fracture • Significant tissue loss/de-gloving • Consider home help/district nursing for elderly or disabled • Consider child care for primary carer of under 5s • May require physiotherapy to restore normal function continued … 167 Identifier Read Code Patient Education 168 Crush Injury Upper Arm continued SF203 continued • RICE • Avoid HARMS (within the first 72 hours) • Care of stitches (see Wound Management Overview) • Rest as much as practicable until area comfortable • Rest arm in broad arm sling until pain free • Elevate affected limb when at rest until swelling settles Need for prompt reassessment if: • Patient taking anticoagulants • Severe pain not relieved by simple analgesia or elevation of the affected limb • Severe pain disproportionate to the injury • Changes in colour or sensation peripheral to the injury • Untoward swelling – advise patient what to expect and when to return • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Unable to manage daily living or work Crush Injury Wrist or Hand Identifier Read Code Key Points Crush Injury Wrist or Hand SF22. • Assess compartment syndrome risk • Assessment of neurovascular and tendon function important in open wounds • Refer de-gloving injuries • Meticulous wound management Complications • Compartment syndrome/ischaemic contracture(s) if not recognised • Nerve injury • Fracture and tendon rupture • Reflex sympathetic dystrophy syndrome – complex regional pain syndrome • Infection • Loss of function History • Comprehensive nursing assessment • Mechanism of injury: – Crush – Machinery (rollers) – Wringer • Associated injuries • Hand dominance • Current medications, especially anticoagulants and allergies • Co-morbidities, especially diabetes and immunocompromise • Tetanus immunisation status Assessment (According to Competency) • Devitalised tissue • Assess each muscle compartment for swelling and impending compartment syndrome • Skin laceration/abrasion • Assess for presence of foreign bodies • Refer to medical practitioner for assessment of neurovascular impairment: – Motor function: » Motor » Ulnar nerve – finger ab/adduction » Radial nerve – wrist extension » Median nerve – function of abduction pollicis brevis/thumb opposition to fingers – Sensory: » Ulnar nerve – tip of little finger » Radial nerve – dorsal 1st web space » Median nerve – tip of index finger » Digital nerves – 2-point discrimination on ulnar/radial borders of all finger pulps • Assess tendon function • Crepitus for bony injury Differential Diagnosis • Cellulitis • Laceration • Fracture • Nerve injury • Major vessel injury continued … 169 Identifier Read Code Investigation Crush Injury Wrist or Hand continued SF22. continued • Refer for X-ray and reporting as appropriate (to exclude fracture or foreign body if risk) • Ultrasound may be indicated if suspicious of non-radio-opaque foreign body Action Plan • Treat associated injuries as indicated • Analgesia as required by prescription or standing orders • Tetanus prophylaxis (see Wound Management Overview) • Open wounds: – Document neurovascular status – Immediate medical referral if suspicious of compartment syndrome – Either refer to medical practitioner or, according to competency, filtrate local anaesthetic for irrigation and meticulous debridement – Close wounds if appropriate – Simple dressings to keep covered and protected – Splinting of limb in appropriate position if extensive wound or over joint – Elevate in sling – Review wounds in 24-48 hours – Antibiotic prophylaxis if high risk (see Wound Management Overview) • Closed injury: – Document neurovascular status – Immediate medical referral if suspicious of compartment syndrome – Elevate in sling – Review in 24-48 hours Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do any work tasks with injury • For assessment, investigations or treatment, if outside individual area of competency • Signs/Symptoms suggestive of (or significant risk of) compartment syndrome: – Severe pain, especially on passive extension (earliest and most sensitive sign) – Severe swelling – Neurological impairment – Diminished pulses or perfusion (late sign) • Extensive wound(s) for debridement and management • Nerve/Tendon injury • Fracture • Significant tissue loss/de-gloving Other Referral • Consider home help/district nursing for elderly or disabled • Consider child care for primary carer of under 5s • May require specialist hand physiotherapy continued … 170 Identifier Read Code Patient Education Crush Injury Wrist or Hand continued SF22. continued • RICE • Avoid HARMS (within the first 72 hours) • Care of stitches (see Wound Management Overview) • Rest as much as practicable until area comfortable • Rest arm in sling until pain free • Elevate affected limb until swelling settles • Complete pain assessment and provide adequate pain relief via standing orders or prescription – avoid aspirin Need for prompt reassessment if: • Patient taking anticoagulants • Severe pain not relieved by simple analgesia or elevation of the affected limb • Severe pain disproportionate to the injury • Changes in colour or sensation peripheral to the injury • Untoward swelling – advise patient what to expect and when to return • Signs or symptoms of infection – local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever • Unable to manage daily living or work 171 Crush Injury Finger(s)/Thumb (Open and Closed) Identifier Read Codes Key Points Crush Injury Finger(s)/Thumb (Open and Closed) SF23./SF231 • Meticulous assessment of tendon and nerve function important • A subungal haematoma causing pain should be drained to provide relief • Trephining a subungal haematoma in the presence of a fracture constitutes a compound fracture • Consider medical referral for nail removal and nail bed repair if subungal haematoma >50% • Consider tendon rupture/division • Avoid sutures where possible Complications • If open wound: – Osteomyelitis from unrecognised compound fracture – Wound infection • All crush injuries: – Separation of new nail from nail bed if significant nail bed injury – Nail deformity if nail matrix injury – Extensor tendon damage – Collateral ligament rupture – Finger/Thumb pulp ischaemia – Loss of mobility History • Comprehensive nursing assessment • Mechanism of injury: – Blow with implement e.g. hammer – Crush in door • Machinery • Current medications, especially anticoagulants and allergies • Co-morbidities, especially diabetes and immunocompromise • Tetanus immunisation prophylaxis Assessment (According to Competency) • Distal capillary return (circulation) • Presence of subungal haematoma and size • Presence of mallet finger deformity (avulsion extensor tendon) • Clinical likelihood of fracture • Degree of swelling • Joint injury – limitation of movement • Sensation in finger – digital nerve injury Differential Diagnosis Investigation • Cellulitis • Refer for X-ray and reporting as appropriate – to exclude fracture if indicated and exclude presence of any potential foreign body • Swab for culture and sensitivity if infected continued … 172 Identifier Read Codes Action Plan Onward Referral Crush Injury Finger(s)/Thumb (Open and Closed) continued SF23./SF231 continued • Analgesia as required by prescription or standing orders • Tetanus prophylaxis (see Wound Management Overview) No fracture (and no nerve, tendon injury): • Elevate in high sling • If significant subungal haematoma causing pain, trephine with heated paper clip or sterile needle if within competency or refer to medical practitioner • Consider medical referral for nail removal and nail bed repair if subungal haematoma >50% • Mobilise early • Suspected fractures, nerve, tendon and ligament injuries, splint appropriately and refer to medical practitioner: – Prophylactic antibiotic therapy is necessary following trephination only where there are additional indications or there is significant baseline bacterial contamination, for example in human or animal bites/puncture wounds/fractures UCL rupture: • see Sprains/Strains: Sprain Thumb S522. Tendon and nerve injury: splint appropriately and refer to medical practitioner Circulatory impairment: • Gross swelling, pain, poor capillary return • Urgent medical referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury • Suspected fractures • Suspected tendon injury • Suspected nerve injury • Suspected ligament rupture/instability • Digital nerve injury • Impaired circulation • Nail bed injury/subungal haematoma >50% • May require specialist hand physiotherapy • Consider home help for disabled or elderly continued … Comment Although trephination of subungal haematoma using heated paper clips remains a simple, common and straightforward procedure, this practice remains somewhat primitive and has hazards related to it being performed incorrectly. The use of disposable electrocautery devices is considered more current and humane. These devices should take no longer than 1 second to reach optimal white hot temperatures. These devices minimise the risk of introducing carbon filament foreign bodies or “lampblack” associated with traditional heated- paper clip techniques (Chang & Carter 2000). These devices are thought to help reduce pain and trauma to the site caused by premature coagulation of the haematoma (Smilanich & Lammers 1995). Using a sterile needle should be strongly advised against. Super-heated needles will certainly puncture the nail but the over-exuberance of the practitioner can cause unnecessary trauma to the nail bed from too much pressure and the super-sharp needle point (Scott & Flannery 2003; Seaberg, Angelos & Paris 1991; Smilanich, Bonnet & Kirkpatrick 1995). 173 Identifier Read Codes Patient Education 174 Crush Injury Finger(s)/Thumb (Open and Closed) continued SF23./SF231 continued • RICE • Avoid HARMS (within the first 72 hours) • No fracture (and no nerve, tendon injury): – Rest as much as practicable until area comfortable – Rest arm in high sling until pain free – Elevate affected limb when at rest until swelling settles – Trephined nail requires further dressings – Mobilise affected finger early – Continue regular analgesia until pain settles – avoid aspirin • Tendon injury • Mallet finger injury: – Rest as much as practicable until area comfortable – Rest arm in high sling until pain free – Elevate affected limb when at rest until swelling settles – Manage in appropriate splint – Keep splint in place for 6 weeks – Mobilise as instructed by physiotherapist or medical practitioner – Continue regular analgesia until pain settles – avoid aspirin • Care of stitches (see Wound Management Overview) • Need for prompt reassessment if: – Patient taking anticoagulants – Trephined nail requires further dressings – Severe pain not relieved by simple analgesia or elevation of the affected limb – Severe pain disproportionate to the injury – Changes in colour or sensation peripheral to the injury – Untoward swelling – advise patient what to expect and when to return – Signs or symptoms of infection – local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever – Unable to manage daily living or work Closed Crush Injury Foot Identifier Read Code Key Points Closed Crush Injury Foot SF322 • Meticulous assessment of X-ray by medical practitioner or radiologist as Lis-Franc (tarsometatarsal) fractures of the mid-foot are difficult to diagnose and have serious consequences • If unable to weight bear, refer to a medical practitioner Complications • Osteoarthritis • Chronic pain • Reflex sympathetic dystrophy – complex regional pain syndrome • Unrecognised fractures of mid-foot with mal-union • Loss of function History • Comprehensive nursing assessment • Mechanism of injury: – Crush injury – Road trauma – Foot run over • Co-morbidities, especially diabetes, immunocompromise and peripheral vascular disease • Social support and family responsibilities • Tetanus immunisation prophylaxis Assessment (According to Competency) • Active and passive range of movement toes and foot • Circulatory impairment • Degree of swelling • Presence of wounds or abrasions • Deformity • Presence of bony tenderness suggesting fracture • Sensory deficit suggesting nerve injury • Ability to bear weight Differential Diagnosis Investigation Action Plan • Gout • Cellulitis Onward Referral • Refer for X-ray and reporting as appropriate • Complete pain assessment and provide adequate pain relief by standing orders or prescription • Regular application of ice compresses in first 24 hours • Elevate as much as possible • Support if severe in form of bandaging or splinting • Tetanus prophylaxis (see Wound Management Overview) • If unable to weight bear and/or fracture is suspected, needs medical referral for further treatment • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some duties with injury • Circulatory impairment • Nerve injury • Unable to weight bear • Possibility of fracture • Significant soft tissue injury continued … 175 Identifier Read Code Other Referral Patient Education 176 Closed Crush Injury Foot continued SF322 continued • May require physiotherapy if delay in return to function • May require home help/district nursing • RICE • Avoid HARMS (within the first 72 hours) • Support in form of splinting if severe • Continue regular analgesia until pain settles – avoid aspirin • Care of stitches (see Wound Management Overview) • Need for prompt reassessment if: – Patient taking anticoagulants – Severe pain not relieved by simple analgesia or elevation of the affected limb – Severe pain disproportionate to the injury – Changes in colour or sensation peripheral to the injury – Untoward swelling – advise patient what to expect and when to return – Signs or symptoms of infection – local heat, increasing tenderness, inflammation, offensive odour/discharge, swelling, systemic illness including fever – Unable to manage daily living or work Section Six: Miscellaneous Overview.......................................................................................................................................................179 Anaphylaxis Treatment Protocol..................................................................................................................179 Body Fluid Exposure...................................................................................................................................182 Infection Control........................................................................................................................................184 Head Injury Risk Group...............................................................................................................................186 Glasgow Coma Scale..................................................................................................................................187 Codes and injuries S60.. Concussion........................................................................................................................188 E2A2. Post Concussion Syndrome................................................................................................195 F542. Tympanic Membrane Perforation........................................................................................197 JO510/S8363 Loss of Teeth (Accidental)/Broken Teeth.............................................................................199 M2y5. Foreign Body in Skin or Subcutaneous Tissue.....................................................................202 SD810/SG00. Corneal Abrasions/Corneal Foreign Body............................................................................205 SG1../SG2.. Foreign Body in Ear/Foreign Body in Nose..........................................................................209 SG5.. Ingested Foreign Body........................................................................................................212 TE532 Toxic Reactions Bee Stings.................................................................................................215 SL… Toxic Ingestions (Activated Charcoal).................................................................................218 Spider Bites.......................................................................................................................220 TE60./U120. Dog Bites/Human Bites/Cat Bites......................................................................................222 TL01. Electrical Injury..................................................................................................................227 SN571 Management of Sexual Assault/Abuse in General Practice.................................................231 177 178 Miscellaneous Overview Anaphylaxis Treatment Protocol Anaphylaxis is a potentially life-threatening immune response to an allergen. Key Points • There is no place for conservative management of anaphylaxis • Early administration of adrenaline in association with fluid replacement is the mainstay of treatment • In general, the more severe the reaction, the more rapid the onset. Most life-threatening reactions begin within 10 minutes of exposure to the allergen. The intensity usually peaks at around 1 hour after onset. Symptoms limited to only 1 system can occur, leading to delay in diagnosis • Biphasic reactions where symptoms recur 8-12 hours after the onset of the original attack and prolonged attacks lasting up to 48 hours have been described Aetiology and Recognition of Anaphylaxis • Parenteral penicillin, hymenopteran (bees and wasps) stings and foods are the commonest causes of anaphylactic fatalities • Radiocontrast media, aspirin or other NSAIDs are the most common cause of anaphylactoid fatalities (same range of clinical features although not requiring previous exposure) • Characteristically occurs in otherwise fit patients • The speed of onset reflects the severity of the reaction • Most symptoms occur within 30 minutes, although symptoms can be delayed for some hours, especially with topical or oral exposure • The clinical features described below may occur in combination or as isolated features. The diagnosis may be simple in the classic presentation, however a presentation with isolated hypotension may be more difficult • Late deterioration may occur in around 5% of individuals; therefore patients in whom adrenaline is used should be hospitalised for 6-8 hours • In severe cases, up to 50% of the circulating volume can be lost from the vascular compartment Signs and Symptoms timelines signs and symptoms severity Early warning signs Dizziness, tingling, warmth, pruritus Mild Flushing, urticaria, nasal congestion, sneezing, lacrimation, angioedema, erythema (especially weals) Mild to severe Hoarseness, nausea, vomiting, laryngeal oedema, dyspnoea, abdominal pain/cramps Moderate to severe Bronchospasm, stridor, syncope, hypotension, dysrhythmias, coma, confusion Life-threatening Late, life-threatening symptoms 179 Distinguishing Anaphylaxis from a Faint (Vasovagal Reaction) faint anaphylaxis Usually at the time or soon after the injection Usually a delay of 5-30 minutes after injection Skin Pale, sweaty, cold and clammy Red, raised and itchy rash; swollen eyes, face; generalised rash Respiratory Normal to deep breaths Noisy breathing with airway obstruction (wheeze or stridor); respiratory arrest Cardiovascular Bradycardia; transient hypotension Tachycardia; hypotension; dysrhythmias, circulatory arrest Gastrointestinal Nausea/Vomiting Abdominal cramps Neurological Transient LOC; good response once prone LOC; little response once prone Onset SYSTEM Adapted from Chapter 2: Processes for Safe Immunisation, page 53: Immunisation Handbook 2002: Ministry of Health Action Plan 1st-line treatment: • • • • • • • • • • • Call for help. Send for medical assistance/other staff, medical practitioner Do not leave the patient alone Lie the patient supine or place in the recovery position if unconscious Appropriate emergency equipment must be immediately at hand whenever immunisations are given Assess the degree of cardiovascular collapse/shock from the pulse and BP recordings Assess the degree of breathing difficulty. Is there stridor, wheeze, or other signs of respiratory distress or airway swelling? If stridor present, elevate head and chest Oxygen by face mask 10-15 L/min – can be discontinued if cutaneous manifestation only. Oxygen should not be administered if the patient is hyperventilating as this can cause additional reactions such as fainting and panic Monitor consciousness, airway, breathing and circulation by pulse, BP and respiratory recordings every 5-10 minutes and document fully, including all symptoms and treatment given Raise the legs if BP low Adrenaline: – Adults 0.5 mg DEEP IM i.e. 0.5 ml of adrenaline 1:1000 (adrenaline 1:1000 = 0.01 mg per 0.01 ml) Repeated at 5-10-minute intervals according to response – Children – dose dependent on weight/age Either 180 Or age (yrs) dose (mg) <2 0.0625 2-5 0.125 6-11 0.25 >11 0.5 0.01 mg/kg (IM i.e. 0.1 mls/kg of 1:10,000) Repeated at 5-10-minute intervals according to response, to a maximum of 3 doses. NB: Only medical practitioners should administer IV adrenaline. You can expect to see some response to the adrenaline within 1-2 minutes. If necessary, adrenaline can be repeated at 5-15-minute intervals to a maximum of 3 doses, while waiting for assistance. Use alternate sites/ limbs for additional doses. • Insert IV line if within area of competency or enlist urgent medical assistance – fluids: 10-20 ml/kg colloid or crystalloid IV according to medical instruction or standing orders then repeated according to haemodynamic parameters • Admit to hospital for observation – rebound anaphylaxis can occur 12-24 hours after initial episode. Observation for 24 hours after stabilisation of the patient’s condition is recommended due to the risk of late deterioration from delayed and biphasic reactions 2nd line treatment: according to standing orders or prescription • Nebulised beta-agonists: – Adrenaline if predominant stridor 1 mg diluted to 4 ml with saline and repeat as necessary – Salbutamol if predominant bronchospasm 5 mg • Antihistamines: – H1 blockers (promethazine or diphenhydramine) are of most value when the allergic condition is mildmoderate, progressing slowly and dominated by cutaneous manifestations – They may be used in combination with H2 blockers e.g. ranitidine – Both may be initially given IV by medical practitioner, later orally for 2-3 days • Steroids: – Role in reducing protracted symptoms, especially bronchospasm – Discharge medication to reduce likelihood of relapse of symptoms – 2-3-day course • Aminophylline: – Severe bronchospasm resistant to adrenaline – 5 mg/kg over 30 minutes with cardiac monitoring • Glucagon: – Consider in patients on beta-blockers who may have more symptoms that are difficult to treat; 1 mg IV repeated every 5 minutes if necessary • Beta-blocked patients may require additional doses of adrenaline • Report the reaction to CARM, PO Box 913, Dunedin 9054, using the pre-paid postcard H1574 Patient Education • If allergen known, consider applying for Medical Alert bracelet or necklace through medical practitioner • Inform patient to keep personalised information data sheet from Medic Alert Foundation in their wallet or purse at all times • Consider prescription from medical practitioner for adrenaline auto injector for subsequent emergency treatment. Note contraindications and cautions for use • Advise patient to carry adrenaline auto injector at all times • Teach patient how to recognise symptoms of anaphylaxis • Recall patient to educate in first-line treatment for future anaphylaxis. • Advise the patient to: – Not hesitate injecting themselves with adrenaline into the anterior thigh – Immediately call for ambulance – Use their 2nd adrenaline auto injector if they do not improve or continue to deteriorate. In a severe reaction, an adrenaline auto injector simply “borrows time” until help arrives • Where applicable, advise patient not to expose themselves to the known allergen again e.g. not to ingest peanuts/fish, not to take penicillin again • Advise patient to inform a close family member of their allergen • Return immediately for medical attention if any further signs of rebound anaphylaxis occur • In the case of anaphylaxis occurring in a child, the public health nurse should be advised in order that the school can be educated in the management of the child’s reaction 181 Body Fluid Exposure With permission to reprint from Medlab South Ltd, 2004 Recording and monitoring of accidents and serious harm is a requirement of the Health and Safety in Employment Act 1992 and the Health and Safety in Employment Amendment Act 2002. Definitions: • Recipient – the person exposed to the blood or body fluid • Donor – the person whose blood or body fluid was inoculated or splashed onto the affected person Types of Contacts to be Reported 1. Injury resulting from contact with used needles or sharp objects (e.g. scalpel blades) that have been contaminated with blood or body fluids 2. Splashing of blood or body fluids onto a mucous membrane (e.g. eyes or mouth) or onto a fresh cut or burn (usually less than 24 hours old) 3. A scratch/bite which breaks the skin Following Exposure • Encourage bleeding from the wound and cleanse vigorously with copious amounts of soap and water. (Alcohol based rinses/foams should be used when water is not available) • Cover the wound with an adhesive waterproof dressing • For eyes, nose or mouth, rinse thoroughly with clear running water or saline Define Exposure Doubtful parenteral exposure: • Superficial injury with a needle considered not to be contaminated with blood or body fluid • Superficial wound not associated with visible bleeding produced by an instrument considered not to be contaminated with blood or body fluid • Prior wound or skin lesion contaminated with a body fluid other than blood and with no trace of blood Possible parenteral exposure: • Superficial injury with a needle contaminated with blood or body fluid • A wound not associated with visible bleeding produced by an instrument contaminated with blood or body fluid • Prior (not fresh) wound or skin lesion contaminated by blood or body fluid • Mucous membrane or conjunctival contact with blood Definite parenteral exposure: • Skin penetrating injury with a needle contaminated with blood or body fluid • Injection of blood/body fluid not included under “Massive Exposure” • Laceration or similar wound which causes bleeding and is produced by an instrument that is visibly contaminated with blood or body fluid • Any direct inoculation with human immunodeficiency virus (HIV) tissue or material likely to contain HIV, Hepatitis B virus (HBV) or Hepatitis C virus(HCV) not included in above – this refers to accidents in laboratory settings Massive exposure: 182 • Transfusion of contaminated blood • Injection of large volumes of contaminated blood/body fluid (>1 ml) • Parenteral exposure to laboratory specimens containing high titre of virus Management Following Exposure Incident with body fluids which may be considered HIGH RISK – please contact: Regional Infectious Disease Specialist or Infectious Serology Department at regional laboratory as soon after the incident as possible. Exposure to an HIV positive source requires that testing be carried out within 2-4 hours post-exposure as the recipient may require antiretroviral therapy. This may only be undertaken after counselling by an approved consultant. DO NOT WAIT FOR BLOOD TEST RESULT 10 mls of blood should be drawn from the affected person and the source individual (if known) and sent to the laboratory for Hepatitis B, C and HIV testing as soon as possible. (A needle or sharp object from an unknown source may be transported in a clearly labelled puncture resistant container.) A laboratory requisition form and appropriate needle stick protocol blood/serum/body fluid contact report form should accompany the blood to the laboratory. All laboratory results are confidential to the person concerned and their medical practitioner. Requisition Form Nurses may not sign laboratory requisition form without the authorisation of a medical practitioner. Protocol Form Nurses must not sign the patient consent on the protocol form. It must be signed by the patient or their medical practitioner. The signature on the form will be taken as consent for HBV, HCV and HIV testing unless they are crossed out. Results Staff results are reported to the medical practitioner nominated by the staff member on the protocol form and requisition form. The medical practitioner will be contacted if there is any concern. This medical practitioner will be responsible for providing treatment as necessary. Staff member results are not reported back to an institution where the incident occurred without the express permission of the staff member. It is the responsibility of the staff member to inform their employer of the laboratory results if they desire to. Staff members may obtain their own results from their medical practitioner or upon written request from the laboratory. Medlab South Ltd, November 26, 2002 183 Infection Control Instruction and Protocol for Blood/Body Substances Injuries 1. Immediately report the incident to your supervisor 2. Complete an incident form and include: • Date, time and type of exposure (e.g. hollow needle, slash, lancet, breast milk) • How the incident occurred (indicate whether the wound bled) • Name (if known) of the donor (a needle/syringe of unknown origin should be kept for testing, should this be required) All employees who sustain a needlestick injury or body fluid exposure are at risk of acquiring a blood-borne disease. 3. Arrange for blood pathology testing to be taken from the employee within 24 hours of exposure • Post-Injury tests – stat: – HBsAb (even if previously vaccinated) = Hepatitis B Virus Surface Antibody – HCVAb = Hepatits C Virus Antibody – HIVAb = Human Immunodeficiency Virus Antibody – Take 1 10 ml red top tube of blood (in needlestick pack) Blood testing should be treated as URGENT (intervention for HBV exposure should occur within 72 hours) • At 6 months and 12 months: – HCVAb – HIVAb – Take 1 10 ml red top tube of blood NOTES: • Reassure the employee that only a small proportion of accidental exposures result in infection • Consult the laminated wall chart for more information Hepatitis • If an employee is not immune to HBV, vaccination is required • If employee is not immune but has been vaccinated previously, vaccine booster only is required (HBsAb to be repeated 1 month after vaccination). This is only appropriate when immunity has resulted from previous vaccine • If the donor is HBsAg positive or is a high risk for Hepatitis B, Hepatitis B immunoglobulin should be administered within 36 hours. This is not required if an adequate HBsAb level is present (>10 IU/L) HIV • If the donor is HIV positive or from a high-risk group, treatment with Zidovudine (AZT) and other antiretroviral agents should be considered • Careful documentation is recommended; ACC may be relevant • Following the needlestick injury/exposure, AZT mono therapy is considered to reduce the risk of HIV transmission 5-fold • Combination therapy with 3 oral agents (AZT, Lamivudine (3TC) and Indinavir (IDV)) for 4 weeks after exposure is recommended following a high-risk injury (To be effective it must be commenced within 2 HOURS of exposure) If the donor is negative for HBV, HCV and HIV, no further immediate action is required. Repeat testing of the exposed person at 6 and 12 months should be considered as the donor may have been in the antibodynegative phase (window phase) of these infections. 184 Injury from unknown donor Where a needlestick injury has been caused by a needle/syringe of an unknown donor (especially if this occurs outside the health care setting), some risk of stratification can be attempted by testing the contents of the syringe. If present, HBsAg and HIV antibodies can be detected and a drug screen can determine whether the syringe was used for IV drug abuse; the risk of HCV may be significant. REVIEW safe work practices as well as vaccination status of staff. All health care workers should be vaccinated against HBV. (HBsAb levels should be measured 1 month after completing a vaccination course). Recommendation for Chemoprophylaxis after Occupational Exposure to HIV, by Type of Exposure and Source material, 1996. (Ministry of Health) antiretroviral prophylaxis antiretroviral regimen Highest risk Recommended AZT plus 3TC Increased risk Recommended AZT plus 3TC plus IDV No increased risk Offer AZT plus 3TC type of exposure source material Percutaneous Blood +/– IDV** Mucous membrane Fluid containing visible blood, other potentially infectious fluid, or tissue Offer Other body fluid (e.g. urine) Not offer Blood Offer AZT plus 3TC AZT +/– 3TC AZT plus 3TC +/– IDV Skin, increased risk Fluid containing visible blood, other potentially infectious fluids, or tissue Offer Other body fluid (e.g. urine) Not offer Blood Offer AZT +/– 3TC AZT plus 3TC, +/– IDC** Fluid containing visible blood, other potentially infectious fluids, or tissue Offer Other body fluid (e.g. urine) Not offer AZT +/– 3TC **Possible toxicity of additional drug may not be warranted. 185 Head Injury Risk Group Key Points High Risk • 2% of all head injuries, 30% have intracranial injury • Drowsy/Confused (GCS <14) • Focal neurological signs • Delayed convulsion • Deteriorating recordings or symptoms e.g. GCS fall by 2 points • Penetrating skull injury or palpable depressed fracture • Basal skull fracture signs: – Bilateral periorbital bruising (Raccoon’s eyes) – Blood or CSF from nose, ear or blood behind ear drum – Bruised mastoid area (Battle’s sign) Moderate Risk • • • • 23% of all head injuries, 4% have intracranial injury GCS 14 Severe or worsening headache, especially if accompanied by vomiting Serious facial injury: – Suspected impingement onto brain tissue: » Scalp injury/assault with firm, pointed object » Gunshot, missile, shrapnel » Possible depressed skull fracture • Bleeding disorder or anticoagulation • Unreliable history of injury (e.g. language difficulties) Minor Risk • 75% of head injuries, minimal risk of intracranial injury • None of the above criteria • Mild headache • Dizzy • Scalp haematoma/laceration/contusion/abrasion ONLY “The Grey Zone” • Any history of: – LOC (KO’d, amnesia) – Recurrent vomiting 186 a c S a m o C w o g s Gla le e best. orst and 15 th , 3 being the w 15 d an 3 n ee Response. 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It m w w w at e lin e and on e full guidelin included in th is ix nd pe ap Note: This clinical use. 187 Concussion Identifier Read Code Key Points Red Flag nts: High-risk patie s ar • >40 ye ofessionals with • Students, pr itive complex cogn jobs involving demands le • Skilled peop ith psychiatric w • Individuals types or personality histories and/ dependence • Alcohol/Drug injury ussion or head • Previous conc • Child at risk Complications Concussion S60.. • See also Head Injury Risk Group (Miscellaneous Overview) • See also Clinical Guidelines/Acute Management Traumatic Brain Injury ACC601 • History of injury is critical, particularly reports from other people/ bystanders • Frequent neurological assessment necessary to recognise progressive deterioration. Record observations serially • May need neurophysiological assessment for reaction to safety issues related to machinery at work • Neurological status is the most important indicator of risk (see Red Flags ) • X-rays/CT scans do not always identify damage or complications • Intracranial haemorrhage can safely be ruled out only by CT/MRI scan • Patients should only be discharged: – When fully alert – With competent observer who can arrange prompt reassessment – With written advice sheet (see Resources) • Head-injured individuals should be warned that post-concussion symptoms are to be expected • Athletes will need clear advice about length of time off. Guidelines based on neurological assessment have been published (available on ACC’s Injury Prevention website www.sportsmart.org.nz) • Concussion may be missed in patients with other life-threatening conditions or multiple injuries • Post Concussion Syndrome E2A2. (decreased concentration, headaches, sleepiness, fatigue, irritability, dizziness) • Cerebral contusion • Intracranial haemorrhage – operable (subdural, extradural, some intracerebral haematoma) • Intracranial haemorrhage – inoperable (traumatic subarachnoid haemorrhage) • Post-traumatic epilepsy • Persistent hearing loss/sensory problems • Risk of second impact syndrome (a 2nd blow to the head, while still suffering the effects of a prior concussion, can cause serious cerebral oedema out of proportion to the energy of the 2nd injury) continued … 188 Identifier Read Code History Concussion continued S60.. continued • Comprehensive nursing assessment • Mechanism of injury: – Force of impact – Distance of fall – Vehicular speed • Pattern of patient’s clinical course from time of injury • Current clinical and neurological status (see Miscellaneous Overview: Glasgow Coma Scale) • Modification of normal response in children <5 years • LOC • Patient’s recollection of events: – Retrograde/Anterograde amnesia • Associated injuries, especially cervical spine • Recreational drug use (including alcohol) • Current medications, especially anticoagulants and allergies • Co-morbidities, including psychiatric history • Presence of associated symptoms: – Lightheadedness – Vertigo – Tinnitus – Blurred vision/diplopia (double vision) – Headache – Nausea/Vomiting – Photophobia – Balance disturbance • Duration of symptoms if post concussion • Ensure that the reported mechanism of injury correlates with the physical symptoms that are evident, and consider child abuse if suspicious continued … 189 Identifier Read Code Assessment (According to Competency) Differential Diagnosis Concussion continued S60.. continued • Initial focus on airway, breathing and circulation (BP and pulse rate). See Red Flag. Monitor vital signs every 10 minutes for the 1st hour then according to progress. Record including times: – Protection of cervical spine – Neurological state • Full neurological assessment or refer to medical practitioner: – GCS score (see Miscellaneous Overview). Note the time of assessing the GCS. By convention the GCS at 1 hour is considered critical – Pupils – Focal neurological signs in limbs – Assessment of II, III, IV, VI, VII, VIII cranial nerves – Assessment of cerebellar function • Head and neck examination: – Nose (CSF rhinorrhoea) – Ears (bleeding from canal) – Cervical tenderness • Mental status: – Orientation – Immediate memory – Concentration – Delayed recall • Look for basal skull fracture signs: – Bilateral periorbital bruising (Raccoon’s eyes) – Blood or CSF from nose, ear or blood behind ear drum – Bruised mastoid area (Battle’s sign) • Exclude other injury • Test speech, vision co-ordination • Drug/Alcohol intoxication Diagnosis by medical practitioner: • Intracranial haemorrhage: – Extradural – Subdural – Intracerebral • Stroke (CVA) • Drug and/or alcohol intoxication • Psychiatric disorder • Post-ictal • Metabolic disturbance e.g. hypoglycaemia • Other medical causes e.g. infection continued … 190 Identifier Read Code Investigation Concussion continued S60.. continued Referral to medical practitioner for CT head scan if (see Red Flags ): • Focal neurological signs • Deteriorating level of consciousness (as assessed by GCS score) • All patients with GCS <13 • All patients GCS 14 (drowsy, confused) with failure to improve at 3-4 hours. (NB: These patients will need admission for close observation anyway) • Suspected or proven penetrating head injury • Patients in whom neurological assessment is difficult (due to alcohol or other drug use, language difficulties) • Persistent associated symptoms: – Severe headache – Vomiting • Compound head injury Refer to medical practitioner for skull X-ray: • Possibility of depressed skull fracture in otherwise well patient (impact with sharp objects or objects with small surface area) • Young children with normal conscious state and clinical suspicion of fracture • Suspicion of compound skull fracture where conscious level normal and CT scan unavailable (due to distance) • Cervical spine X-ray if indicated • Audiogram if hearing loss continued … 191 Identifier Read Code Action Plan Concussion continued S60.. continued Resuscitation: Obtain immediate medical assistance • Assess airway, breathing and circulation and treat as appropriate • Prevent hypoxia and hypotension • Attention to other injuries • Stabilise cervical spine if indicated and within scope of practice • Urgent referral by medical practitioner if indicated for CT head scan +/– admission High risk: Obtain immediate medical assistance • Protect and X-ray cervical spine if drowsy • Stabilise airway, breathing, circulation • Urgent head CT • Refer to neurosurgeons promptly Moderate risk: Obtain immediate medical assistance • CT is the optimum investigation • Consider skull X-ray only if CT unavailable • Fracture – discuss with neurosurgeon • No fracture – observe for 4 hours then reassess • Ongoing observation for deterioration Low risk: discuss patient with medical practitioner before discharge • Check thoroughly, observe • No need for X-ray or CT • Discharge with advice sheet • Must have observer to check frequently the “Grey Zone” • Refer to medical practitioner for: – Neurological observation if history of recent LOC, with regular reviews and documentation • Mild analgesia (avoid aspirin) on standing orders or prescription • Admission by medical practitioner if condition deteriorates • Insert IV line if within scope of practice or refer urgently to medical practitioner if signs of deterioration On discharge if not hospitalised after discussion with medical practitioner: Patients should only be discharged: • When fully alert • With competent observer who can arrange prompt reassessment • With written advice sheet (available through ACC, see Resources) • Education and explanation to patient and carer • Discharge to competent/responsible caregiver, excluding where child abuse is suspected • Simple analgesia (regular paracetamol, avoid aspirin) • Regular reviews • Avoid driving of motor vehicle until review at 24-48 hours continued … 192 Identifier Read Code Onward Referral Concussion continued S60.. continued • Head-injured individuals should be warned that post-concussion symptoms are to be expected • All high-risk patients • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to so some work tasks with injury • Requirement for urgent CT head scan: – To local ED/neurosurgeon • Requirement for close observation (will be influenced by time of day/ night, presence or absence of responsible carers, nature of injury, age and social situation of patient): – Hospitalise (in patient specialty according to local practices) Medical practitioner to refer or discuss with specialist if: • Skull fracture • Not fully recovered after 4 hours (including presumed intoxication) • Inadequate support and observation at home for next 20 hours • Lives too far from hospital (45 minutes) for prompt return • Abnormal CT scan • Neurological observations show a decline in consciousness/ responsiveness Medical practitioner to refer or discuss with neurologist or psychologist if: • Persistent neuropsychological issues (emotional, sleep, stress disorders) • Children with behavioural or educational issues • Audiology as indicated ACC Life Care team if long-term sequelae continued … 193 Identifier Read Code Patient Education 194 Concussion continued S60.. continued • Advise patient and their family about expected symptoms that may occur following a mild to moderate concussion. Offer written advice sheet (see Resources) • Advise some symptoms are common but are most likely to resolve within 30 days: – Difficulty with concentration, attention and/or memory – Fatigue easily – Disordered sleep – Headache – Vertigo or dizziness – Irritability or aggressiveness – Anxiety, depression or labile mood – Personality changes – Apathy – Intolerance of bright light or loud music • All athletes or sports players should be thoroughly assessed by their medical practitioner prior to returning to sport • Before returning to sport, the athlete or sports player should be: – Free of all unusual symptoms – Able to manage team training without problems – Able to score well on a psychometric test that assesses the person’s perception and decision-making ability • Simple analgesia (regular paracetamol, avoid aspirin) • Avoid driving of motor vehicle until review at 24-48 hours • Advise patient to return for regular reviews if any of the “common” postconcussion symptoms persist continuously or the patient experiences a substantial worsening of pre-existing symptoms • Advise patient to return for review if any significant impairment or deterioration in occupational functioning compared with pre-injury functioning • Advise patient to return for review if any significant impairment or deterioration in social functioning compared with pre-injury functioning Post Concussion Syndrome Identifier Read Code Key Points Post Concussion Syndrome E2A2. • Concussion syndrome consists of a range of symptoms, commonly including headache, dizziness, fatigue, poor memory and/or concentration, irritability, sleep disturbance, restlessness, frustration, sensitivity to noise, blurred vision, nausea, tinnitus • Symptoms may last for weeks to months • The extent to which the syndrome is organic or psychological in origin at any given time is controversial • May occur even after relatively minor head injury • Recovery may be slow (1-3 months) • 5% may still be impaired at 2 years Complications • Psychosocial problems • Employment difficulties • Driving impairment • Impaired life skills History • Comprehensive nursing assessment • Headache • Decreased concentration, memory difficulties • Sleep disorder • Easily fatigued • Irritability/Aggression • Anxiety/Depression/Affective disorder • Dizziness, tinnitus, vertigo • Photophobia, blurred vision • Social, relationship dysfunction • Occupational difficulties • Previous psychiatric history • Symptoms worse after work/exercise • Onset/Worsening of symptoms after head injury Assessment (According to Competency) Differential Diagnosis Investigation • Refer to medical practitioner to rule out intracerebral pathology Action Plan • Education of family and caregivers • Assessment of work safety by appropriate personnel • Psychiatric conditions • Chronic fatigue syndrome • Consider CT scan • Referral for psychometric testing continued … 195 Identifier Read Code Onward Referral Patient Education 196 Post Concussion Syndrome continued E2A2. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • For psychometric testing – attention, memory difficulty • For assessment of driving capacity where appropriate • Psychiatrist • Medical specialist if symptoms >3 months • Head Injury Society • ACC Life Care team • Advise some symptoms are common but are most likely to resolve within 30 days: – Difficulty with concentration, attention and/or memory – Fatigue easily – Disordered sleep – Headache – Vertigo or dizziness – Irritability or aggressiveness – Anxiety, depression or labile mood – Personality changes – Apathy – Intolerance of bright light or loud music • All athletes or sports players should be thoroughly assessed by their medical practitioner prior to returning to sport • Before returning to sport, the athlete or sports player should be: – Free of all unusual symptoms – Able to manage team training without problems – Able to score well on a psychometric test that assesses the person’s perception and decision-making ability • Advise patient to return for regular reviews if any of the “common” postconcussion symptoms persist continuously or the patient experiences a substantial worsening of pre-existing symptoms • Advise patient to return for review if any significant impairment or deterioration in occupational functioning compared with pre-injury functioning • Advise patient to return for review if any significant impairment or deterioration in social functioning compared with pre-injury functioning Tympanic Membrane Perforation Identifier Read Code Key Points Red Flag r is uma to the ea When direct tra l ra eu i-n or ns se associated with e th o d/or vertig hearing loss an d be referred an ld ou patient sh d. ire qu re surgery may be Tympanic Membrane Perforation F542. • Tympanic membrane heals best if kept clean and dry (water raises risk of infection) • Baro-trauma from diving should be discussed with a medical practitioner who may in turn seek advice from dive medicine personnel or an ENT specialist • SCUBA divers with abrupt onset of balance disturbance while diving should be referred urgently to a medical practitioner or directly to dive medicine personnel or an ENT specialist • Most ruptures of the tympanic membrane heal spontaneously within 2-3 weeks; failure to heal is usually due to loss of tissue or infection • Perforations due to welding sparks often fail to heal and should be referred to an ENT specialist • Aural or oral antibiotics are not indicated unless presence of infection (or perforation occurs in contaminated or tropical waters) Complications • Chronic perforation with hearing loss • Infection • Ossicular injury • Permanent hearing loss • Cholesteatoma formation History • Comprehensive nursing assessment • Mechanism of injury: – Blow to ear (especially open hand) – Hot slag from welding or acid entering ear canal – Foreign body insertion e.g. hair clips, cotton buds – Baro-trauma – Syringing – After sudden explosion – Skull fracture • Concurrent/Recent past history of ear infection • Previous ear disease/hearing impairment • Associated symptoms e.g. tinnitus, vertigo, nausea Assessment (According to Competency) • External ear: – Signs of blood or mucous discharge in canal • External ear canal: – Lacerations • Tympanic membrane (site and extent of rupture) • Temperature • Simple conversational assessment of hearing. It must be done without giving the patient visual clues such as the examiner’s lip movement. Cover the non-test ear during the examination. Ask the patient to repeat simple words or numbers. A whisper is about 30 decibels, a softly spoken voice approximately 50 decibels Differential Diagnosis • Fractured floor of skull with bleeding from behind tympanic membrane • Tympanic membrane rupture associated with otitis media • Pulsatile discharge in external auditory canal • Laceration to ear/canal • Bleeding from behind tympanic membrane (haemotympanum) continued … 197 Identifier Read Code Investigation 198 Tympanic Membrane Perforation continued F542. continued • Usually none • If concerns of inner ear damage or persistent impairment of hearing after perforation healed – refer for audiogram Action Plan • Keep ear clean and dry: – Use cotton wool plugs with vaseline or mouldable ear plugs or plastic shower/bathing cap when showering • Aural/Oral antibiotics not indicated unless infection present (or perforation occurs in contaminated or tropical waters). NB: Chronic infections as a result of the perforation can cause major hearing loss • Avoid immersion of head until healed (most heal within 2-3 weeks). No swimming and/or diving • Review until healed, initially 2 weekly then monthly • Audiology when healed – expect healing in 4 weeks • Tetanus prophylaxis (see Wound Management Overview) Onward Referral Urgent consultation with medical practitioner for referral to dive medicine/ ENT if: • Significant history of baro-trauma, especially if associated with balance disturbance or other history of decompression illness or sensori-neural hearing loss. Urgent consultation with medical practitioner for referral to otorhinolaryngologist (ENT specialist): • Tympanic membrane perforation and evidence of ossicular disruption (vertigo, persistent nystagmus, tinnitus) • If perforated when syringing • If the edges of the perforation are ragged and hang into the middle ear, referral is necessary because of the late complication of cholesteatoma formation. The referral needs to be within the first few days following injury Delayed referral to otorhinolaryngologist (ENT specialist): • Persistent hearing impairment after perforation healed • Failure of perforation to heal by 1 month • Perforation due to welding injury, as failure to heal is common • If perforation related to diving, refer for careful medical assessment for evidence of decompression illness and referral to hyperbaric medicine unit as appropriate • Audiologist Patient Education • Keep ear clean and dry: – Use cotton wool plugs with vaseline or mouldable ear plugs or plastic shower/bathing cap when showering • Avoid immersion of head until healed (most heal within 2-3 weeks). No swimming and/or diving • Avoid “cleaning” ears with foreign objects e.g. hair pins, cotton buds. Use only soft cloth and warm water Loss of Teeth (Accidental)/Broken Teeth Identifier Read Codes Key Points Loss of Teeth (Accidental)/Broken Teeth JO510/S8363 • Prevention is preferable to repair – encourage sports players to wear mouth guards • Avulsed permanent teeth should be replanted as soon as possible • Intact avulsed teeth have excellent chance of reimplantation within 4 hours, although success quickly tapers off after 1 hour. The prognosis for replanted teeth is dependent on time out of the mouth and storage conditions while out of the mouth (suitable osmotic solutions e.g. milk, saliva). Aim for replantation ASAP within the hour and store suitably if any delay is inevitable. Before replanting, ensure that there is no debris on the root – wash with saline or briefly in tap water but do not scrub the root. Antibiotics are necessary for avulsed teeth – check on the tetanus status if tooth has contacted soil • Attempt to find all avulsed teeth and tooth fragments • Keep avulsed teeth moist in buccal cavity or milk, but preferably replant tooth • Never handle avulsed teeth by the root • Do not discard teeth or remove loose teeth • Consider associated mandibular or maxillary fracture plus other injuries • Check teeth if there is an injury to the mucosal aspect of lip and ensure careful oral examination • All dento-alveolar injuries require referral to a dentist Complications • Loss of dentition • Infection of gum or pulp/root infection in tooth fractures • Painful TMJ, headaches • Death and/or discolouration of re-implanted tooth History • Comprehensive nursing assessment • Mechanism of injury: – Fall – Direct blow • Initial first aid • Facial or mouth injury • Associated injuries • Tetanus immunisation status Assessment (According to Competency) • Oral cavity – especially tongue and upper and lower labial sulci (stripping lacerations often contain foreign bodies) • Lips – examine under local anaesthesia for tooth fragments (if within individual nurse’s level of competency or refer to medical practitioner) • Alignment of teeth and bite – check occlusion – can they bite together normally? • Loose/Missing teeth – beware apparent avulsed/lost tooth – check inside socket for impaction or backward displacement • Bleeding socket – check for impaction • Check if there is any injury to the mucosal aspect of the lip – teeth can be forced through the lip, causing a “through and through laceration” (sutures will be needed inside and out) • Refer to medical practitioner to examine for mandibular and maxillary fracture – any area of tenderness/swelling away from the direct contact area of trauma e.g. over lower jaw • Refer to medical practitioner if any facial nerve dysfunction – any areas of numbness over the face/lips continued … 199 Identifier Read Codes Differential Diagnosis Loss of Teeth (Accidental)/Broken Teeth continued JO510/S8363 continued • Pulpitis • Dento-alveolar abscess • Gingival inflammation • Alveolar osteitis (dry socket post extraction) • Erupting teeth • Chipped teeth • Fractures of maxilla/mandible • Dental caries, loss of filling Investigation • Refer to medical practitioner if patient has any collateral injury requiring further investigation • Refer for X-ray and reporting as appropriate • CXR if concern about possible tooth or tooth fragment aspiration • Mandibular injury – OPG, PA and lateral X-rays +/– occlusal views • Maxillary fractures – facial X-rays Action Plan • Find and assess avulsed teeth – handle by crown, never by root • Gently wash off dirt with saline or briefly with tap water/do not scrub the root • Transport tooth as appropriate – best location is in socket if tooth intact – replace firmly, stabilise with gauze. Next best is in saline, then milk, or plastic wrap or aluminium foil • Apply pressure to bleeding tooth socket • Simple analgesics as necessary • Avulsed teeth: – Do not attempt to replace if primary dentition • Permanent dentition: – Long-term prognosis depends on early reimplantation – Don’t allow to dry out – Gentle irrigation under running water/saline for 15 seconds: » Replant tooth in socket – support with gauze » Refer immediately to dentist • Broken teeth – may require temporary cover depending on extent of damage • Do not reimplant fragments of tooth – refer, especially if red spot present = pulp laceration • Teeth fragments and debris can contaminate mucosal lacerations – check carefully and clean thoroughly • Repair skin lacerations with 6/0 nylon and 5/0 absorbable suture to muscle e.g. undyed polyglactin to muscle, prior to reimplantation (if within level of competency or refer to medical practitioner) • Tetanus prophylaxis (see Other Soft Tissue Injuries: Overview) continued … 200 Identifier Read Codes Onward Referral Patient Education Loss of Teeth (Accidental)/Broken Teeth continued JO510/S8363 continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury • Refer to medical practitioner to examine for mandibular and maxillary fracture – any area of tenderness/swelling away from the direct contact area of trauma e.g. over lower jaw • Refer to medical practitioner if any facial nerve dysfunction – any areas of numbness over the face/lips Refer to specialist/dentist: • Avulsion of secondary teeth where teeth are available should be referred urgently • Avulsion of primary teeth can be referred non-urgently • Urgent referral if exposed pulp injury • Dentine-only injuries can be referred non-urgently • Refer urgently if infection present • To medical practitioner for referral to faciomaxillary surgeon (or as per local referral practices) if mandibular or maxillary fracture • Encourage sports players to wear properly fitted mouth guards at all times during contact sport • Continue regular pain relief e.g. paracetamol, avoid aspirin • Wash mouth regularly with warm salted water as directed by specialist/ dentist 201 Foreign Body in Skin or Subcutaneous Tissue Identifier Read Code Key Points 202 Foreign Body in Skin or Subcutaneous Tissue M2y5. • Wounds should not be closed if foreign material not completely removed • Most wounds contaminated by <100,000 bacteria/g of tissue heal uneventfully following repair • Good irrigation and a clean technique for repairing wound are essential • Foreign matter greatly enhances the infectivity of a given bacterial inoculation • The procedure is nearly always more difficult than it first appears • Use bony landmarks for identifying location of foreign body (seen on X-ray) • Not all foreign bodies require removal • Glass is nearly always radio-opaque • Historical details are important so appropriate type of imaging is performed if required Complications • Incomplete removal of foreign body(ies) • Neurovascular injury • Infection locally and via tissue planes • Retained foreign bodies are a common complication of simple wound repair and a frequent source of treatment injury complaints History • Comprehensive nursing assessment • Mechanism of injury • Nature of foreign body: – Metal – Glass – Wood – Organic e.g. flax, grass – Plastic • Velocity of foreign body entry • Injury on glass, metal • Penetrating injury e.g. wood/stick/thorn/palm • Tetanus immunisation status Assessment (According to Competency) • Palpate for foreign body • Localise tenderness • Look for puncture wound • Foreign body may be seen in the wound or on X-ray • Refer to medical practitioner for neurovascular assessment before surgical exploration • Presence of infection • Assess for signs of injury to deeper structures: – Sensory deficits – Tendon injuries – Vascular compromise Differential Diagnosis • Laceration • Abscess • Tumour • Infection • Insect bite • Cellulitis continued … Identifier Read Code Investigation Action Plan Foreign Body in Skin of Subcutaneous Tissue continued M2y5. continued Refer for X-ray and reporting as appropriate: • If likely foreign body radio-opaque – X-ray • If likely foreign body non-radio-opaque – ultrasound • Although radiographic studies will identify all retained metallic fragments and more than 90% of glass foreign bodies, retained wood and plastic are often detected only by wound exploration • See also Other Soft Tissue Injuries: Overview • Consider leaving open if foreign body not completely removed or wound has been heavily contaminated • Refer to medical practitioner or standing orders for antibiotics for wounds with a high probability of becoming infected (>10%). This includes wounds repaired more than 12 hours after injury and involving body areas other than the head, heavily contaminated wounds, and wounds in patients with immunocompromising conditions or taking immunosuppressive drugs • Referral to medical practitioner as necessary if neurovascular compromise Superficial or open wound: • Explore under local anaesthetic (according to competency), remove foreign body then treat as normal open wound. NB: Do not use xylocaine with adrenaline for exploration of wounds in extremities e.g. hands/ fingers, feet/toes as high risk of vascular compromise; or • Refer to medical practitioner for exploration under local anaesthetic • Factors to be considered in the decision to either close primarily or delay repair include host factors (age, general health, presence of immunocompromising conditions and immunosuppresive drugs) and wound factors (likelihood of significant bacterial infection, degree of contamination by soil or other organic debris, time since injury, mechanism of injury and site of wound) Deeper foreign bodies: • May need exploration under regional or field block with an ischaemic field (tourniquet). This requires greater expertise and time and will necessitate referral to a medical practitioner • If possible remove under local anaesthetic (according to competency) then treat as normal open wound • Daily/Alternate day dressings, monitor healing • Check tetanus status and decide whether wound is tetanus prone using Ministry of Health guidelines – by standing orders or prescription • Consider antibiotics for pseudomonas-prone wounds (foreign body/ penetrating wound to the sole of the foot via rubber-soled shoes) – by standing orders or prescription • Soil contaminants are removed by copious irrigation which will significantly help healing by decreasing the infection risk • If the wound is not healing, consider: infection, toxic substance, retained foreign body or neoplasm continued … 203 Identifier Read Code Onward Referral Patient Education 204 Foreign Body in Skin of Subcutaneous Tissue continued M2y5. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury For referral to orthopaedic/general/paediatric surgeon as per local practice: • Beyond competence to remove • Inappropriate to remove foreign body due to: – Lack of equipment – Time required – Complexity of procedure due to site involved and expertise • Deep foreign body needing removal • Child requiring GA • Significant neurovascular injury • Involvement of deeper structures: – Major vessel – Nerve – Tendon – Joint/Bone • Simple analgesia as required e.g. paracetamol • Educate in how to keep dressing/wound dry • Instruct in how to manage daily personal hygiene i.e. showering/bathing • Rest as much as possible until wound healed • Elevate limbs if there is swelling or a risk of oedema formation • Return for regular dressings where applicable • Encourage use of safety apparel – e.g. safety boots if further risk of penetrating injury to foot • Advise patient to return if any signs or symptoms of infection, e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • Advise patient of common expected side effects after a tetanus immunisation Corneal Abrasions/Corneal Foreign Body Identifier Read Codes Key Points Corneal Abrasions/Corneal Foreign Body SD810/SG00. • Always assess and record visual acuity before intervention • If blunt or penetrating injury, refer to medical practitioner urgently to check deeper ocular structures • Do not remove a protruding intraocular foreign body • 24-hour follow-up required and daily review until healed • History of metal vs metal and eye symptoms require referral for X-ray to exclude intraocular foreign body • Refer to medical practitioner to examine eye(s) carefully • Always examine after staining with fluorescein • Advise patient of need to wear eye pad or shield eye until anaesthetic drops have worn off – 1-2 hours usually • Photophobia may persist for several days after corneal injury (avoid bright lights, direct sunlight, TV) • Use of pad is contentious for corneal abrasion • Driving is not permitted with a padded eye • Low threshold for medical or specialist referral if not confident with assessment or diagnosis • Continued use of local anaesthetic drops delays epithelialisation, decreases protective reflexes, can cause keratitis – do not give to patient to use Complications • Missed metallic intraocular foreign body leading to siderosis i.e. chronic inflammation • Infection • Cataract • Corneal instability – recurrent corneal abrasion at site of original abrasion • Loss of vision • Scarring of cornea reducing visual acuity • Secondary ophthalmoplegia (paralysis of the muscles of the eye), glaucoma • Persisting rust ring • Prolapsed iris and risk of intraocular infection with persisting eye wounds History • Comprehensive nursing assessment • Nature of foreign body in eye • Mechanism of injury to eye – blow, gardening, fighting, dust, debris, chemical burns • Site of pain – beware unilateral painful red eye • Watering and photophobia • Metal on metal or welding • Use of protective eyewear • Contact lenses • Foreign body sensation (irritation, watering/photophobia) • Previous eye problems Assessment (According to Competency) • Visual acuity (bilateral with pin hole/glasses) prior to instigating treatment • Full eye examination by medical practitioner continued … 205 Identifier Read Codes Differential Diagnosis Corneal Abrasions/Corneal Foreign Body continued SD810/SG00. continued • Conjunctivitis • Corneal ulcer – herpetic, marginal • Corneal burn • Iritis i.e. inflammation of the iris • Keratitis i.e. inflammation of the cornea • Trichiasis i.e. friction or irritation of the cornea due to abnormal position of the eyelashes • Entropion i.e. inversion of an eyelid, so that the lashes rub against the globe of the eye • Contact lens trauma • Acute glaucoma Investigation • Refer for X-ray and reporting as appropriate – if intraocular foreign body suspected (specify up/down gaze views) • Swab – if infection suspected Action Plan • Obtain medical opinion if beyond competence and expertise to assess • Refer to medical practitioner or standing orders for instillation of topical anaesthetic drops to facilitate adequate examination and treatment • Eye should be double padded until anaesthetic wears off (1-2 hours) • Eye padding for longer remains somewhat controversial but tendency is not to pad • Regular systemic (oral) analgesia will usually be required – by standing orders or prescription • Tetanus prophylaxis (see Other Soft Tissue Injuries: Overview) • Follow up until healed Abrasion: • Obtain the full history of the cause of the injury • Compare both eyes • Check sight of both eyes • Confirm foreign body, if possible • Irrigate with saline if indicated • Refer to medical practitioner for full eye examination • Instil amethocaine hydrochloride 1%. Explain pad/pain first. Insert 1 drop, then 2nd drop and repeat if necessary • Remove foreign material if trained to perform procedure or refer to medical practitioner • Check under eyelids • Instil fluorescein sodium 2%, checking for abrasions. Flush with normal saline. Abrasions show up as green areas on sclera • Pad for 4 hours while blink reflex not present • If abrasion >30% cornea or over visual axis, refer to medical practitioner or directly to ophthalmologist for follow-up • Otherwise daily follow-up until healed (usually 24-48 hours) • Caution with abrasions involving organic material (e.g. while gardening) as fungal infection may develop • Instil A/B ointment by standing orders or prescription, continue QID 48 hours • Pain relief by standing orders or prescription continued … 206 Identifier Read Codes Action Plan continued Onward Referral Corneal Abrasions/Corneal Foreign Body continued SD810/SG00. continued Corneal foreign body: • Irrigate with warm water/saline • Refer to medical practitioner or standing orders for instillation of topical anaesthetic drops to facilitate adequate examination and treatment • Stabilise head (preferably seat patient at slit lamp) • Excellent magnification and lighting required • Refer to medical practitioner for short-acting mydriatic e.g. Cyclopentolate 1% TDS for ciliary spasm • Remove foreign body using cotton bud, hypodermic needle or dental burr if trained to perform procedure OR refer to medical practitioner • Refer to medical practitioner for inspection for rust ring, remove following day • A/B ointment by standing orders or prescription, continue QID 48 hours • Pain relief by standing orders or prescription • Daily follow-up until healed Chemical agent: • See Burn Eye and Adnexa SH0.. • Refer to medical practitioner or standing orders for instillation of topical anaesthetic drops to facilitate adequate examination and treatment • Irrigate with warm water/saline for 15-20 minutes, using >1000 ml then refer immediately (as per eye specialist). Continue irrigation until pH 7.0-7.4, recheck after 10 minutes. If uncertainty about pH in alkali burn, continue irrigation during transfer to hospital Intraorbital foreign body: • If obvious – refer immediately. Do not examine further. Prevent further injury – stabilise head, apply eye shield – commercial or styrofoam cup • Do not remove protruding foreign body • Pain relief by standing orders or prescription/consider narcotics • Anti-emetic by standing orders or prescription to prevent raised intraocular pressure • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to perform some work tasks with injury • Obtain primary medical opinion if beyond competence and expertise to assess Urgent referral to ophthalmologist either directly or by primary referral to medical practitioner: • Impaired visual acuity not corrected with pin hole or persisting corneal defect after 48 hours • All full-thickness abrasions/lacerations • Significant infection • Intraocular foreign body • Penetrating eye injury • Hyphaema i.e. haemorrhage into the anterior chamber of the eye • Corneal abrasion >30% cornea or over visual axis • Central visual axis abrasion or foreign body • Unable to remove foreign body completely • Vitreous haemorrhage suspected Delayed referral to ophthalmologist either directly or by primary referral through medical practitioner: • No improvement in size of corneal abrasion at 24 hours continued … 207 Identifier Read Codes Patient Education 208 Corneal Abrasions/Corneal Foreign Body continued SD810/SG00. continued • Do not drive with padded eye • Wear eye pad or shield until anaesthetic drops have worn off – 1-2 hours • Photophobia may persist for several days (avoid bright lights, direct sunlight, TV) • Vital to return for follow-up assessment as instructed • Educate in the appropriate use of safety equipment e.g. safety glasses • Instruct in application, use and storage of eye drops/ointment Foreign Body in Ear/Foreign Body in Nose Identifier Read Codes Key Points Foreign Body in Ear/Foreign Body in Nose SG1../SG2.. • Try to ascertain nature of foreign body • In nose/ear, attempt to get blunt probe/hook (Johnson’s probe or bent paper clip) behind foreign body if visible with the naked eye. Refer for medical treatment if lodged deeper in orifices. Do not use forceps • The procedure is nearly always more difficult than it first appears • Good lighting, correct instruments and possibly additional staff assistance to reassure or restrain the juvenile patient during procedure • Avoid repeated attempts • Wounds should not be closed if foreign material not completely removed • Ear: – Mostly children » Most hard, round objects (e.g. beads) – Refer to medical practitioner if child unco-operative or foreign body beyond the anterior external meatus – Rarely cause problems until unskilled removal is attempted » Can cause permanent damage if child jumps suddenly • Nose: – Mostly children – Most present with unilateral offensive-smelling discharge – Foam plastic, beads, calculator batteries, peanuts – Refer to medical practitioner if child unco-operative or foreign body beyond the anterior external meatus • Disc (button) batteries should be removed within 2 hours; caustic leakage can cause injury to epithelium and cartilage • Avoid use of sharp instruments Complications • Inhalation of foreign body (nose) • Incomplete removal of foreign body • Infection • Damage to tympanic membrane/external auditory canal/ossicular damage • Damage to nasal turbinates/nasal mucosa • Hearing loss History • Comprehensive nursing assessment • Nature of foreign body • Foul-smelling discharge ear/nose • History of child placing foreign body up nose or in ear • Insect in ear • Hearing loss/blocked ear • Previous nasal or ear disease Assessment (According to Competency) Differential Diagnosis • Direct visualisation using headlamp and nasal or aural speculum • Check both sides • Check for damage to ear drum/canal • Aural cerumen • Sinusitis • Otitis externa • Intranasal tumour • Cholesteatoma continued … 209 Identifier Read Codes Investigation Action Plan Foreign Body in Ear/Foreign Body in Nose continued SG1../SG2.. continued • Usually none • Refer for X-ray and reporting as appropriate if any suspicion that a nasal foreign body may have been aspirated • Do not use sharp hook as may increase damage • Refer to medical practitioner if child unco-operative or foreign body beyond the external meatus • Only 1 person should try removing foreign body • Attempt to get blunt, angled probe behind foreign body • Good light source (headlamp), right-angled hook (e.g. paper clip) essential • Tetanus toxoid immunisation, see (Other Soft Tissue Injuries: Overview) Nose: • Refer to medical practitioner or standing orders for the administration of a few drops of 4% lignocaine mixed with a decongestant (e.g. Otrivine) 5 minutes before removal is helpful • Strong exhalation through nose with contralateral nares occluded, if person co-operative (sneeze) • Use nasal speculum (Thuddicum) if available with good light source (preferably headlamp) • Remove using flat, blunt probe, hook (take care not to push object deeper) • Re-examine for signs of mucosal injury or residual foreign body • Low threshold to refer to ENT specialist unless foreign body anterior, good equipment and adequate expertise • Disc (button) batteries remove ASAP – see Key Points Ear: • Requires co-operative, motionless patient • Remove foreign body using canal hook or suction • Live insects can be killed with olive oil, or on medical advice or by standing orders, lignocaine or ophthalmic amethocaine drops – useful to provide topical anaesthesia • May need to irrigate ear gently with warm water • Suction applied if available and by experienced operator (e.g. ENT specialist) • Direct visualisation with speculum and good light source • Removal with flat, angled probe or microalligator forceps if in anterior aspect of auditory canal • Do not use forceps unless close to meatus • Syringing with warm water, directed at the posterior wall of the canal, may facilitate removal in some cases • Disc (button) batteries remove ASAP – see Key Points • Foreign body in medial half of external auditory canal usually requires greater magnification to prevent damage to the tympanic membrane • If in doubt, safer to refer continued … 210 Identifier Read Codes Onward Referral Patient Education Foreign Body in Ear/Foreign Body in Nose continued SG1../SG2.. continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Beyond competence • Risk of damage to ear drum • Failure of 1 person to remove foreign body • If any suspicion that a nasal foreign body may have been aspirated • Refer to medical practitioner or directly to otorhinolaryngologist (ENT specialist) if: – Most foreign bodies in young children (occasional GA required) – Foreign bodies in medial half of external auditory canal • In general, foreign bodies not easily removed • NB: Most foreign bodies are successfully removed without a GA by ENT specialist • Where possible, keep small objects out of range of small children i.e. appropriate toys for age • Be extra vigilant when changing lithium button batteries i.e. dispose of promptly and safely • Encourage children to keep small items out of reach of younger siblings e.g. peanuts, small toys 211 Ingested Foreign Body Identifier Read Code Key Points Red Flag lus that the food bo • If it is likely d/ an s on ag , gluc contains bone not e ar s ge ra ve be or carbonated nt tie and the pa recommended d for urgent rre fe re should be gastroscopy ay e food bolus m • Although th the ith w h ac om st pass into the nt tie pa t, the above treatmen a gastroscopy ve ha ill st should ude -urgent) to excl performed (non y tholog oesophageal pa Ingested Foreign Body SG5.. • Oesophageal foreign bodies causing complete obstruction are usually caused by meat bolus. There may be underlying oesophageal disease • Distal oesophageal obstruction may present with only occasional regurgitation of saliva • Individuals with persistent symptoms of dysphagia despite normal X-ray and indirect laryngoscopy should be discussed with a medical practitioner for referral to an ENT surgeon to determine appropriate action • Most ingested foreign bodies in the paediatric age group do not require repeat (serial) X-rays • Children ingesting high-risk foreign bodies (very long foreign bodies, sharp foreign bodies, button batteries or heavy metals e.g. lead) should have their care discussed with a specialist (paediatric surgeon if available) and may require removal of the foreign body by gastroscopy • The risk of perforation is higher when sharp or pointed metallic objects, animal or fish bones, bread-bag clips, medication blister packs, or toothpicks are ingested Complications • Pharyngeal perforation and mediastinitis i.e. inflammation in the thoracic space between the 2 pleurae • Bowel obstruction/perforation History • Comprehensive nursing assessment • Time and date of ingestion • Nature of agent ingested (if known): – Coin – Button battery – Pins – Food bolus – Chicken/Fish bone • Pain on swallowing • Difficulty swallowing • Previous history of same problem • Prior stroke (CVA) • Known oesophageal disease/abnormality continued … 212 Identifier Read Code Assessment (According to Competency) Ingested Foreign Body continued SG5.. continued • Observe: – Drooling – Respiratory distress » Continuously spitting – Spitting up saliva every few minutes • Level of discomfort: – Patient should point to source of pain – Helpful if above sternal notch – Poor accuracy of localisation if below sternal notch • Palpate neck for tenderness • Inspect: – Tonsillar fossae – Tongue base • Refer for medical assessment of piriform fossae (by indirect laryngoscopy) • Refer for medical assessment to auscultate chest if suggested by symptoms Differential Diagnosis • Existing oesophageal stricture • Other oesophageal disease • Central cause e.g. stroke • Pharyngeal/Oesophageal mucosal abrasion/laceration • Consider aspiration if respiratory symptoms Investigation • Obstructed oesophagus in adult: – Nil • Paediatric ingestions: – Refer for X-ray and reporting as appropriate – chest, neck, abdomen to localise foreign body if radio-opaque • Pharyngeal foreign body in adult: – Refer for X-ray and reporting as appropriate – soft tissues neck continued … 213 Identifier Read Code Action Plan 214 Ingested Foreign Body continued SG5.. continued Obstructed oesophagus in adult: • A number of agents have been used to relax smooth muscle and allow passage of the food bolus with variable success – Glucagon 1 mg IV/IM on the orders of a medical practitioner or standing orders – Carbonated beverage orally e.g. Coke – If unsuccessful, or unable to use these agents (see Red Flag ), refer for urgent gastroscopy Paediatric ingestions: • The majority of swallowed foreign bodies are asymptomatic and pass through the gut without problems • If symptoms of choking, or difficulty swallowing or drooling, refer to medical practitioner for urgent investigation and treatment with admission to hospital by emergency services • Children who have ingested high-risk foreign bodies (very long foreign bodies, sharp foreign bodies, button batteries, heavy metals e.g. lead) need close follow-up and may need urgent gastroscopy. Their care should be discussed with a medical practitioner and/or paediatric surgeon or referral as per local practices Pharyngeal foreign body in adult: • Often sharp – chicken/fish bone • Occasionally may be seen on X-ray – on direct referral or via medical practitioner • If no foreign body seen on X-ray or on indirect laryngoscopy but persistent symptoms, discussion with medical practitioner and/or telephone consultation with ENT specialist is recommended and followup as agreed (may be delayed a few days) • If foreign body seen, referral to ENT specialist may be necessary for removal Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury Obstructed oesophagus in adult: • Refer for urgent assessment by medical practitioner for urgent referral to gastroenterology/ENT specialist – as per local referral practices (usually distal to gastroenterologist and proximal to ENT, although referral practices vary) Paediatric ingestions: • All oesophageal foreign bodies – refer to medical practitioner for referral to ENT specialist or paediatric surgeon as per local referral practice • Some foreign bodies below diaphragm e.g. button battery, very long foreign bodies, sharp foreign bodies, heavy metals (lead) – urgent specialist referral (paediatric surgeon if available) for close observation/ gastroscopy Pharyngeal foreign body in adult: • Urgent medical opinion on treatment and referral • To ENT specialist Patient Education • Where possible, keep small objects out of range of small children i.e. appropriate toys for age, foods for age • Be extra vigilant when changing lithium button batteries i.e. dispose of promptly and safely • Encourage children to keep small items out of reach of younger siblings e.g. peanuts, small toys Toxic Reactions Bee Stings Identifier Read Code Key Points Toxic Reactions Bee Stings TE532 • Reaction may be local, urticarial without systemic reaction or generalised/systemic reaction • Sting to cornea may cause more serious damage • Oxygen, adrenaline, fluids for anaphylaxis • Generalised toxic reaction – observe closely, usually admit to hospital • Stings to throat or mouth may cause airway obstruction • Anaphylactic reactions are most commonly caused by: – Food (nuts, fish and shellfish, dairy, eggs) – 61% – Stinging insects (bees, wasps) – 20% – Medications (aspirin, NSAIDs, antibiotics) – 8% Complications Local: • Erythema, infection • Impaired circulation in distal extremity from secondary oedema • Corneal ulceration (from corneal sting) • Retained foreign body (stinger), granuloma, skin necrosis Generalised: • Serum sickness-like illness at 10-21 days • Unusual complications include encephalopathy, neuritis, vasculitis, nephrosis i.e. any renal disease, coagulopathy, renal failure • Anaphylaxis History • Comprehensive nursing assessment • Date/Time/Number of stings (>30 stings more likely to be fatal) • Time of onset of symptoms in relation to original time of sting(s) • Past history of stings (most fatalities occur in patients with a history of recent sting causing severe/generalised reaction) • Identify insect • Position of sting (face/body) • Past history of anaphylaxis • Tetanus immunisation status • Current medication and allergies • Symptoms of itching, sneezing, tongue swelling, shortness of breath Assessment (According to Competency) • Vital signs: pulse rate, BP, respiratory rate and level of consciousness • Skin rash • Presence of stings – number and site • Site(s) of sting(s) for erythema and swelling, check if sting still in place • Circulation distally • Signs of shock: poor tissue perfusion, confusion, hypotension • Signs of anaphylaxis: see Miscellaneous Overview – Anaphylaxis Treatment Protocol • Stings to mouth or pharynx – observe for airway obstruction If generalised: • Pharyngeal, facial, neck oedema • Hypotension • Airway obstruction • Arrhythmias • Abdominal signs continued … 215 Identifier Read Code Differential Diagnosis Toxic Reactions Bee Stings continued TE532 continued • Urticaria • Other invertebrate bite, especially ants, wasps, spiders • Localised infection • Other causes of anaphylaxis, circulatory collapse • Corneal abrasion/laceration – if corneal sting Investigation If generalised reaction: • Pulse oximetry if available • Cardiac monitor if available Action Plan • Use the pressure immobilisation method. The lymphatic system is compressed, preventing the venom leaving the puncture site • Remove stinger by brushing sideways with a sharp fingernail or the edge of a knife or credit card – don’t squeeze the poison sac during the removal of the barb • Apply ice to reduce the swelling • Firmly bandage the area if possible, but not tight enough to cause numbness, tingling or any colour change to the extremities • Check for Medical Alert bracelet or necklace • Resuscitation, treat as appropriate Local: • 20% aluminium sulphate cream/spray – denatures venom • RICE and paracetamol (by standing orders or prescription) • Application of topical anti-inflammatory or steroid cream by standing orders or prescription • Localised reaction: – Large local reaction may benefit from systemic steroids for 2-3 days – refer for assessment by medical practitioner – Sting to eye – refer for assessment by medical practitioner – Sting to mouth or pharynx – observe closely for airway obstruction » Antihistamine by standing orders or prescription. Refer to medical practitioner as required • Generalised toxic reaction (due to multiple stings): – Refer for medical assessment – Supportive care – May require adrenaline if features of anaphylaxis (bronchospasm or hypotension) – Usually hospitalise for more prolonged observation as other organ dysfunction may develop Anaphylaxis (see Miscellaneous Overview – Anaphylaxis Treatment Protocol): • Obtain staff/medical assistance immediately • Adrenaline • Oxygen • Admit to hospital Other: • Mouth or throat sting: be prepared for intubation if New Zealand Resuscitation Council Inc trained to >Level 6 or refer to medical practitioner for close observation • If generalised symptoms continue for 2-4 hours, refer to medical practitioner • Tetanus prophylaxis see Other Soft Tissue Injuries: Overview continued … 216 Identifier Read Code Onward Referral Patient Education Toxic Reactions Bee Stings continued TE532 continued • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work with injury • Emergency paediatric transfer if <14 years • If anaphylaxis, generalised toxic reaction or airway obstruction – to local ED by ambulance/helicopter • Sting to eye – discuss with medical practitioner and/or ophthalmologist or refer directly • Delayed referral to allergy specialist for assessment if severe or life-threatening anaphylaxis • Slow response to treatment or relapse (systemic reaction) • Pregnant with systemic reaction • Immunocompromised/Other serious medical problems • Application for adrenaline auto injector • Consider applying for Medical Alert bracelet or necklace • Inform patient to keep personalised information data sheet from Medic Alert Foundation in their wallet or purse at all times • Consider prescription from medical practitioner for adrenaline auto injector for subsequent emergency treatment. Note contraindications and cautions • Instruct patient to carry adrenaline auto injector at all times • Instruct patient in recognition of symptoms of anaphylaxis • Recall patient to educate in first-line treatment for future anaphylaxis. Instruct the patient to: – Not hesitate injecting themselves with adrenaline into the anterior thigh – Immediately call for ambulance – Use their 2nd adrenaline auto injector if they do not improve or continue to deteriorate. In a severe reaction, an adrenaline auto injector simply “borrows time” until help arrives • Do not inject into feet, hands, nose, buttocks or genitalia. Keep well clear of the face • Do not inject intravenously • Advise patient to inform a close family member of their allergen 217 Toxic Ingestions (Activated Charcoal) Identifier Read Code Key Points Toxic Ingestions (Activated Charcoal) SL… • Identify the poison • Contact National Poisons Centre – telephone 0800 POISON (0800 764 766) • If toxic dose taken, give activated charcoal as detailed below • If activated charcoal given, refer patient to local ED • Don’t use Ipecacuana Activated charcoal is the primary method for the gastrointestinal decontamination of the majority of toxic ingestions. Chemical processes increase its surface area and enable activated charcoal to adsorb a wide range of toxic compounds, preventing or reducing their absorption by the gastrointestinal tract. Activated charcoal is effective for a wide range of compounds, and it is easier to list those for which it is not effective. The following is a list of compounds for which activated charcoal is not indicated: • Acids/alkalines • Hydrocarbon compounds (e.g. alcohols, glycols, petroleum distillates) • Ionised compounds (e.g. iron, fluoride, potassium, lithium) Activated charcoal is administered orally, and while it may be instilled via a nasogastric tube, this may be hazardous, is rarely required and should only be performed following consultation with the National Poisons Centre or a local emergency physician. Contraindications • Activated charcoal is contraindicated when: – Bowel sounds are absent – The toxic compound is not effectively bound by activated charcoal It is recommended that the National Poisons Centre, or its guidelines, be consulted prior to the use of activated charcoal to ensure its effectiveness for the substance involved. Dosage Recommendations for the Treatment of Toxic Ingestions Dosage guide: • The usual recommendation for single-dose activated charcoal is: – Children – 1 g/kg – Adults – 50 g Use of activated charcoal solutions with cathartics (e.g. sorbitol) is not recommended. Activated charcoal is most effective if administered while a toxic ingestant is still in the stomach. As liquids transit more quickly than solids, the window of opportunity for administering activated charcoal is smaller for liquids. It is therefore recommended that for: • Liquids: – Activated charcoal should be administered within half an hour of ingestion, if indicated • Solids: – Activated charcoal may be administered up to 4 hours after ingestion, and for some compounds, longer continued … 218 Identifier Read Code Action Plan Toxic Ingestions (Activated Charcoal) continued SL… continued Activated charcoal is administered orally. Children may object to drinking the black and gritty solution. It is therefore recommended: • Children be encouraged in a firm, friendly manner, preferably in the presence of a caregiver • Use of a straw with an opaque, covered container to increase acceptance As a last resort a flavouring agent (e.g. a flavoured drink) may be added to increase palatability, but this will decrease the effectiveness of the activated charcoal . If a child will not accept activated charcoal, nasogastric intubation to instil activated charcoal should not be routinely attempted. Nasogastric Intubation: Instillation of activated charcoal via nasogastric intubation is only recommended for highly toxic compounds which meet all of the following requirements: • Are readily absorbed to activated charcoal • Have no antidotes • The timeframe is acceptable • Symptomatic and supportive care alone is unlikely to lead to a satisfactory outcome All cases should be discussed with a general practitioner, the National Poisons Centre or a local emergency physician prior to attempting the procedure. Adverse effects: The major adverse effect of single-dose activated charcoal is inadvertent pulmonary aspiration of charcoal that may lead to asphyxia or bronchiolitis obliterans. National Poisons Centre: The National Poisons Centre is available to give advice 24 hours a day, 7 days a week. Telephone 0800 POISON (0800 764 766) Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury Patient Education • Advise parents/caregiver of National Poisons Centre, a 24-hour service for free advice on poisons and poison prevention, as well as emergency advice in the event of poisoning – 0800 POISON (0800 764 766) • Store poisons, such as household cleaners, detergents and medicines, up high and out of sight of children • Install child safety catches on cupboard doors • Ask your pharmacist to use child safety caps on all medicines (some of these caps may involve a small additional cost) • Store poisonous substances in their original containers – never in food or drink containers • Keep handbags containing medicines out of reach of children • Supervise children closely when visiting other homes – where poisons may not be stored as safely as in your own home • Safely dispose of all poisons, such as unused medicines, garden chemicals and cleaning fluids • Learn how to recognise poisonous plants – call the National Poisons Centre on 0800 POISON (0800 764 766) 219 Spider Bites Identifier Read Code Key Points Spider Bites • Reactions may be local, urticarial without systemic reactions or generalised/systemic reactions • Generalised toxic reactions – observe closely, usually admit to hospital Complications Local: • Erythema • Swelling at site of bite • Infection • Irritation – stinging, burning sensation, impaired sensation • Impaired circulation in distal extremities from secondary oedema • Necrotising arachnidism Generalised: • Nausea and vomiting • Muscle spasm • Anaphylaxis • Chills/Fever History • Comprehensive nursing assessment • Identify type of spider (encourage the patient to attempt to capture the spider without further endangering themselves, to describe it or to identify it from a picture of New Zealand indigenous spiders) • Date and time of bite • Position of bite • Past history of spider bites • Past history of anaphylaxis • Current medication and allergies • Tetanus immunisation status • Symptoms of itching, sneezing, tongue swelling, shortness of breath Assessment (According to Competency) • Vital signs: pulse, BP, respiratory rate and level of consciousness • Site of bite for erythema and swelling • Circulation of distal extremities • Signs of shock: poor tissue perfusion, confusion, hypotension • Signs of anaphylaxis see Miscellaneous Overview – Anaphylaxis Treatment Protocol If generalised: • Pharyngeal, facial, neck oedema • Hypotension • Airway obstruction Differential Diagnosis • Other invertebrate bites, especially ants, wasps continued … 220 Identifier Read Code Action Plan Spider Bites continued continued Resuscitation – treat as appropriate Local: • Clean wound with warm, soapy water or antiseptic solution • Apply small ice pack or cold compress to the bite • Paracetamol by standing orders or prescription • DO NOT APPLY PRESSURE • Contact the National Poisons Centre (0800 POISON 0800 764 766) for further advice Localised reaction: • Large local reactions may benefit from systemic steroids for 2-3 days (refer to medical practitioner) • Systemic antihistamines (refer to medical practitioner) Generalised toxic reaction (refer to medical practitioner): • Supportive care • May require adrenaline if features of anaphylaxis (bronchospasm and/ or hypotension) refer Miscellaneous Overview – Anaphylaxis Treatment Protocol • Usually hospitalised for more prolonged observation as other organ dysfunction may develop • Anaphylaxis refer Miscellaneous Overview – Anaphylaxis Treatment Protocol: • Adrenaline • Oxygen – high flow via mask • Arrange for immediate transfer by ambulance/helicopter to nearest hospital Necrotising arachnidism • Secondary stage – necrotising arachnidism (may be associated with white tail spider bites) Treatment • There is no cure for necrotising arachnidism • Supportive care • Regular observations and dressings Onward Referral • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Medications – including antibiotics and corticosteroids Referral to specialist for: • Hyperbaric oxygen therapy – for large compound areas • Surgery and debridement • Skin grafting Patient Education • Regularly clear spider webs from houses, especially living and sleeping areas • Visually check behind furniture etc before placing your hands in secluded places where spiders may have webs • Use chemical sprays that claim to kill insects and/or spiders to stun the spider before killing it to capture for identification • Contact the National Poisons Centre 0800 POISON (0800 764 766) for advice • Fill sandpits to the rim to discourage spider infestation • Trim shrubbery around play area • Clear play equipment of spider webs • For reporting spiders associated with recently imported goods, contact Ministry of Agriculture and Forestry 0800 809 966 221 Dog Bites/Human Bites/Cat Bites Identifier Read Codes Key Points Dog Bites/Human Bites/Cat Bites TE60./U120. • Infection risk with all bites (cat bites 75%; human and dog bites 5-20%) • Human bite risk factors: – MCP joints => ascending tendon infection – Tooth vs head in child => subgaleal (scalp) infection – Finger => deep tendon infection • Animal bite risk factors: High risk: – Hand, wrist or foot – Scalp in infants (risk of skull penetration) – Over joint – Punctures and heavily crushed injuries – Age >50 years – Co-morbidities (asplenia, chronic alcoholic, diabetic, immunocompromise, peripheral vascular disease) Low risk: – Face – Large, minimally contaminated wound, easily irrigated – Superficial wounds and abrasions • Adrenaline in local anaesthetic and deep sutures increase infection rate • Critical treatment strategy is thorough wound cleansing • Teeth fragments may be in wounds • Erythromycin is not an appropriate antibiotic for bite wounds • Close follow-up at 24-48 hours advisable, especially with cat bites • Check tetanus status • At the time of the presentation, documentation of injuries is important not only for the continuity of treatment but also medico legally. Many of the cases eventually involve litigation for assault or negligence with pets Complications • Infection – fulminant sepsis, DIC, renal failure in those immunocompromised • Cat scratch fever (Bartonella henselae) • Nerve, vessel, muscle, bone and joint injury • Septic arthritis History • Comprehensive nursing assessment • Time since injury • Age of patient • Medical history: – Asplenia or liver disease – Metabolic or circulatory problems – Immunocompromised • Tetanus immunisation status • Species of mammal • Associated injuries • History of possible exposure to rabies (bite in foreign country with incidence of rabies) • Consider child/domestic abuse continued … 222 Identifier Read Codes Assessment (According to Competency) Differential Diagnosis Investigation Dog Bites/Human Bites/Cat Bites continued TE60./U120. continued • Site (check for multiple sites) – consider injuries to dorsum of MCP joint as human bite wounds until proven otherwise • Nature of wounds, depth, foreign body, tissue loss • Explore wounds over nerve, bone, tendon, joint, artery if within competency or refer for medical assessment • Assess movement, circulation, nerve supply • Palpate for evidence of gas in tissues • Extent of bleeding • Penetration/Injury to joint • Evidence of active infection – temperature, pulse, localised erythema/ heat • Cellulitis or systemic toxicity if delayed presentation • Other causes of lacerations/puncture wounds • Cellulitis • Usually none • If evidence of active infection – swab for culture and sensitivity • If concern about bony involvement/penetration of joint or teeth in wound – refer to medical practitioner or directly for X-ray • Blood culture if toxic if proficient in venepuncture or refer to appropriate personnel • Consider CT for skull bites in children – may need primary medical referral to activate this continued … 223 Identifier Read Codes Action Plan Dog Bites/Human Bites/Cat Bites continued TE60./U120. continued • Stop bleeding by applying gentle but firm pressure • Explore wound under local using PLAIN anaesthetic (if trained in the use of local anaesthetics) or refer to medical practitioner for treatment. NB: Do not use local anaesthetic with adrenaline for exploration of wounds as it increases infection rate • Remove foreign material and obviously necrotic material. NB: Meticulous debridement with as much tissue preservation as possible • Copious irrigation with saline or povidone-iodine 10% solution (diluted with saline to 1 part povidone-iodine and 10-20 parts saline). Irrigation through a 19-20-gauge needle, 50 ml syringe. The amount necessary – 100-250 ml or more depending on degree of contamination • Closure (avoid deep sutures, may need delayed primary closure at 3-4 days if high-risk wound – see Key Points) if trained and proficient in suturing or refer to medical practitioner • Suspicion of exposure to rabies if patient has sustained bite overseas in rabies endemic country – discuss with infectious disease specialist • Tetanus prophylaxis (see Other Soft Tissue Injuries: Overview) • Pressure bandage dressing • Immobilise and elevate if appropriate • Review daily for 3-5 days • Treat associated injuries as appropriate Dog bites: • Usually primary closure unless: – 12 hours old – Puncture wounds – Hand lacerations – High-risk wound, see Key Points – Almost always close bites on face – Refer to medical practitioner for consideration of antibiotic prophylaxis – controversial. Usually not necessary unless high risk factors, see Key Points. Amoxycillin with clauvulanate. If penicillin allergic, cotrimoxazole or doxycycline metronidazole or clindamycin – 3-5-day course continued … 224 Identifier Read Codes Action Plan continued Onward Referral Dog Bites/Human Bites/Cat Bites continued TE60./U120. continued Human bites: • Primary closure usually avoided unless cosmetic concerns (e.g. facial bite) • Prophylactic antibiotics usually indicated except for the most superficial human bite wounds – see above • The common punch injury with wound over dorsum of MCP joint is notoriously prone to infection and septic arthritis – urgent specialist referral advised either directly or by primary referral to medical practitioner • Consider transmission of organisms such as human immunodeficiency virus (HIV), HBV and even syphilis. If assailant known, follow Chemoprophylaxis table (see Miscellaneous Overview) Cat bites: • Usually puncture wounds with deep penetration • Avoid closure • High infection incidence • Prophylactic antibiotics usually indicated unless minor scratch – see above • Close follow-up Legal issues: Where legal proceedings may ensue following a dog/human/cat bite, obtain consent to photograph bites prior to treatment and/or accurately document their location, size, depth and the amount of trauma including collateral trauma and/or draw to scale, as patient records may be used in the legal proceedings. Use a ruler/measure in the photographs to demonstrate accurately size (plastic wound graphs are useful) and include the NHI or ACC claim number in the photo, to identify the patient. • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury • Spreading cellulitis if not responding to treatment • Nerve damage • Penetration of joint • Significant ear/nose damage • Asplenia or liver disease if infected • Hand and foot wounds if infected • Facial bite wounds (especially children) where optimal cosmetic result imperative – to plastic surgeon e.g. lip or eyelids involved • Extensive wound(s) requiring considerable time/debridement/ exploration – orthopaedic or plastic surgeon • Associated fracture • Infected wound requiring extensive debridement • Wound with significant tissue loss • Many young children who may require sedation or GA to facilitate wound care • Punch injuries to dorsum of MCP joint – to orthopaedic (hand) specialist • Concern about rabies exposure – to infectious disease specialist continued … 225 Identifier Read Codes Patient Education 226 Dog Bites/Human Bites/Cat Bites continued TE60./U120. continued • Simple analgesia as required e.g. paracetamol, avoid aspirin • Educate in how to keep dressing/wound dry • Instruct in how to manage daily personal hygiene i.e. showering/bathing • Rest as much as possible until wound healed • Elevate limbs if there is swelling or a risk of oedema formation • Return for regular dressings where applicable – close follow-up at 24-48 hours advisable, especially for cat bites • Advise patient to return if any signs or symptoms of infection e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • Advise patient of common expected side effects after a tetanus immunisation Electrical Injury Identifier Read Code Key Points Electrical Injury TL01. • Electrical injuries can be divided into high voltage (>1000 V) and low voltage (<1000 V) • Lethal cardiac dysrhythmias occur at the time of exposure • Exposure to electricity depolarises electrically active tissue (cardiovascular and nervous systems) and burns tissue due to heat generated • Other injuries may result from subsequent trauma e.g. fall • Individuals suffering high-voltage electrical injury should be hospitalised • Individuals suffering low-voltage electrical injury may be safely managed in the community providing certain criteria are met – see Action Plan • Electrical burns are usually most severe at the source and ground contact points. It is not possible to predict the amount of underlying tissue damage based on the amount of cutaneous involvement • At the time of the presentation, documentation of injuries is important not only for the immediate resuscitation of the victim but also medico legally. Many cases of electrical injury eventually involve litigation for negligence, product liability or occupational health and safety failure Complications • Compartment Syndrome Sk0Y. • Rhabdomyolysis (a potentially life-threatening syndrome resulting from the break-down of skeletal muscle fibres with leakage of muscle contents into the circulation) and myoglobinuria (a positive urine myoglobin test provides supportive evidence/tea-coloured urine). Patients usually recover completely if the syndrome is recognised early and treated promptly so that late complications are prevented • Neurological impairment • Scarring from burns History • The victim of an electrical burn may not be able to give an adequate history, either because of the severity of injury and accompanying shock and hypoxia or because of unconsciousness or confusion that often accompanies less severe injuries. The history may have to be gathered from the bystanders and personnel who accompanied patient from the accident site • Mechanism of injury: – Domestic – Industrial – Activity involved • Voltage exposure: – Low <1000 V – High >1000 V • Date and time of injury • First aid administered • Pattern of injury • Co-morbidities, especially ischaemic heart disease • Medications and allergies • Tetanus immunisation status continued … 227 Identifier Read Code Assessment (According to Competency) Differential Diagnosis Investigation Action Plan Electrical Injury continued TL01. continued • Initial focus on airway, breathing, circulation and neurological state if appropriate • Assess and record vital signs – continue at regular intervals according to condition • Assess associated injuries e.g. if subsequent fall • Secondary survey: – Thermal burns (entry/exit wounds) – Muscle tenderness – Presence of fractures – Evidence of neurological impairment • Assess for evidence of compartment syndrome • Other causes of thermal injury • 12-lead ECG • Resuscitation as necessary • Treat associated injuries as indicated • Refer to medical practitioner for analgesia as indicated (opiates may be necessary) • Tetanus prophylaxis see (Other Soft Tissue Injuries: Overview) High voltage: • Burns should be cooled for 20 minutes – see Burns Overview • Then cover with sterile drape • Referral to hospital for admission – may necessitate primary referral to medical practitioner – close observation, cardiac monitoring • Insertion of an IV cannula or refer to medical practitioner if outside competency • Analgesia as above continued … 228 Identifier Read Code Action Plan continued Onward Referral Electrical Injury continued TL01. continued Low voltage: • If no LOC, no evidence of neurovascular or muscle injury, a normal ECG and no history of ischaemic heart disease – patient can be safely discharged following where applicable a medical assessment • If any of the following are present, the patient should be referred to hospital for further assessment and observation: directly or by primary referral to a medical practitioner: – History of LOC – Neurological injury (motor weakness/sensory deficit) – Muscle injury (muscle tenderness/pain/swelling) – Vascular injury (acute ischaemia or loss of pulses) – Abnormal ECG (to be read by medical practitioner) or history of ischaemic heart disease • Associated injuries may necessitate admission to hospital • Burns should be treated as per Burns section • Ventricular fibrillation is more common with alternating current at lower voltages e.g. domestic supply Lightning strike: The commonest immediate injuries in lightning strike are: • Skin burns • Central nervous system injury • Cardiac dysrhythmias • Injuries to eyes • Injuries to hearing • Muscle weakness Eye damage: • About half of all lightning victims will incur some eye damage, the majority having corneal injuries. Cataracts may develop immediately or as late as 2 years after the strike. A whole range of other eye injuries can occur Hearing damage: • This is usually caused by the shock wave and is particularly common in people who are struck whilst on the telephone • Muscular paralysis or weakening • May be dramatic but usually resolves within hours. (Department of Public Health and General Practice, 2004) • Some patients will require time off work because of their injury • All patients must be examined by a medical practitioner before they can be issued with a certificate for incapacity to work. Consider whether able to do some work tasks with injury To local ED: • All high-voltage electrical injuries • Some low-voltage injuries – see Action Plan Treat electrical burns as per crush injury because of the large amount of tissue damage that is often present under normal-appearing skin. continued … 229 Identifier Read Code Patient Education 230 Electrical Injury continued TL01. continued Low voltage, no evidence of neurovascular or muscle injury: • Simple analgesia as required e.g. paracetamol, avoid aspirin • Educate in how to keep dressing/wound dry • Instruct in how to manage daily personal hygiene i.e. showering/bathing • Rest as much as possible until wound healed • Elevate limbs if there is swelling or a risk of oedema formation • Return for regular dressings where applicable – close follow-up at 24-48 hours • Advise patient to return if any signs or symptoms of infection e.g. local heat, increasing tenderness, inflammation, offensive odour, swelling, systemic illness including fever • Advise patient of common expected side effects after a tetanus immunisation • Children – recommend use of safety plugs in all electrical sockets within children’s reach • Encourage use of isolators/transformers when using extension cords, especially out of doors • Discourage using power tools/electrical equipment with electrical cords draped across floor or across doorways • When in doubt, or unskilled, leave home maintenance to the professionals Management of Sexual Assault/Abuse in General Practice Identifier Read Code Key Points Management of Sexual Assault/Abuse in General Practice SN571 • Know your limitations. If you have not had in-depth training in counselling or psychotherapy, do not attempt to be a sexual abuse counsellor for your patient • Sexual assault/abuse is a crime • A history of sexual assault/abuse is very common in general practice (up to 30% of patients) and such patients are at more risk of both short- and long-term negative impacts on physical and psychological health • Management commonly (always with children) requires a multidisciplinary approach with involvement of judicial, child-protective and other social agencies • Management may be forensic as well as therapeutic • Nurses should act within the limits of their training and experience and refer appropriately, particularly if untrained in the management of sexual assault/abuse • ACC has contracted with accredited DSAC doctors to provide free medical assessments of sexual assault • Document carefully – may have medico-legal significance. If 1st person told of the assault – document verbatim questions and responses • Do not ask leading questions and do not seek information beyond that required to attend to the immediate emotional and medical needs of the patient i.e. do not attempt to take a full and detailed history of the assault • Provide empathy and reassurance, listen to the patient’s immediate emotional and medical needs • Refer all cases to a medical practitioner for further follow-up and referral to appropriate agencies continued … 231 Identifier Read Code Onward Referral 232 Management of Sexual Assault/Abuse in General Practice continued SN571 continued Refer to medical practitioner: • Recognise and treat physical injury • Attend to the emotional impacts on patient and family/intimates with non-judgemental, supportive approach and provision of appropriate counselling • In New Zealand under the Contraception, Sterilisation and Abortion Act 1977, it is a legal requirement to provide protection against pregnancy after rape • Screen for STDs and/or provide prophylaxis and/or treatment when indicated • Attend to patient safety with appropriate referral to Police/child protection agencies/Women’s Refuge/family and friends • Arrange medical follow-up to ensure adequate progress in all of the above Referral to accredited DSAC doctor for forensic considerations: • A forensic medical examination is a specialised examination undertaken by a forensic medical examiner who is specially trained • It involves taking a detailed history of the assault, a comprehensive physical and genital examination, the collection of samples for a forensic science laboratory and recording of all findings using the protocol and kit supplied by the Police • The procedure may take up to 3 hours • The examining doctor is required to give expert opinion for the Police and later to a court of law on the significance of any findings in relation to allegations of sexual assault Practical advice for provision of supportive approach • Allow patients to tell their story, acknowledge their trauma and that a crime has been committed • Reassure patients that what they are feeling is part of a post-traumatic response. Immediate crisis reactions include numbness, shock, disbelief and anxiety that may last for days to weeks. Subsequent emotional reactions include continued feelings of helplessness, depression, sleep disturbances, nightmares, flashbacks, guilt, selfblame and shame • Patients often feel guilty for not struggling. Reinforce the fact that this may have helped them survive the assault • 3 statements that should be part of consultation: – You are safe now (but don’t say this if it is not true) – I am sorry this happened to you (or in your own words convey empathy and your belief in the worth of this patient) – It’s not your fault (gently draw attention to how patient is blaming themselves e.g. “It sounds as if you are blaming yourself for that”) Glossary/Abbreviations +/- Plus/Minus > Greater than < Less than 3TC Lamivudine AC Acromio-clavicular ACC Accident Compensation Corporation ACL Anterior cruciate ligament ADLs Activities of daily living AE Above-elbow AP Anterior – posterior ASAP As soon as possible AZT Zidovudine BKPOP Below knee plaster of paris BP Blood pressure BSA Body surface area CMC Carpometacarpal CoHb Carboxyhaemaglobin COPD Chronic obstructive pulmonary disease CRP C-reactive protein CSF Cerebro spinal fluid CT Computer tomography CVA Cardio vascular accident CVS Cardio vascular system CXR Chest X-ray DIC Disseminated intravascular coagulation DIP Distal interphalangeal DSAC Doctors for Sexual Abuse Care DVT Deep vein thrombosis ECG Electrocardiograph ENT Ear, nose and throat ESR Elevated sedimentation rate FBC Full blood count FDP Flexor digitorum profundus GA General anaesthetic GCS Glasgow Coma Scale GORD Gastro oesphageal reflux disease 233 HARMS Heat, Alchohol, Running, Massage, Smoking HBsAB Hepatitis B Virus Surface Antibody HBV Hepatitis B virus HCV Hepatitis C virus HCVAb Hepatitis C Virus Antibody HIV Human immunodeficiency virus HIVAb Human Immunodeficiency Virus Antibody IADLs Instrumental activities of daily living IDV Indinavir IM Intramuscular IP Interphalangeal IV Intravenous kg Kilogram LBP Low back pain LCL Lateral collateral ligament L/min Litres per minute LOC LOC MC Metacarpal MCL Medial collateral ligament MCP Metacarpal phalangeal mg Milligram ml Millilitres MRI Magnetic resonance imaging MT Metatarsal MTP Metatarsal phalangeal MVA Motor vehicle accident N Nerve NSAIDs Non-steroidal anti-inflammatory drugs N/Saline Normal saline 234 OPG Panorex X-ray ORIF Open reduction internal fixation PA Posterior – anterior PCL Posterior cruciate ligament pH Measure of acidity and alkalinity of a solution PIP Proximal interphalangeal POP Plaster of Paris PR Per rectum PU Per rethra PUD Peptic ulcer disease PV Per vagina QID Four times a day (sometimes written as qid) RA Rheumatoid arthritis R/C Rotator cuff RCL Radial collateral ligament RICE Rest, Ice, Compression, Elevation RTW Return to work STDs Sexually transmitted diseases STAT Immediately TDS Three times a day (sometimes written as tds) U+E Urea and Electrolytes UCL Ulnar Collateral Ligament UV Ultraviolet V Volts VMO Vastis medialis oblique 235 236 Appendix 1 Pain Identification and Management of Pain Overview What is Pain? Pain is defined as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in the terms of such damage, or both. (International Association for the Study of Pain.) Pain is a subjective experience, and cannot be directly measured. It is influenced by attitudes, beliefs, personality and previous experiences of pain. It may consist of different components – affective, behavioural, cognitive, sensory and/or physiological. Pain may have more than 1 cause and aetiology, and/or be in multiple locations. Pain is real to the person who is experiencing it, whether or not the clinician is able to find a reason for the pain, and the patient’s report should be accepted. Self-report is the most reliable indicator of pain’s existence and intensity; pain is what the person says it is. The inability to report pain (e.g. infants, aphasic patients) does not mean that pain is not present. Why Identify and Manage Pain? Pain causes suffering and negatively affects functioning and quality of life. American studies suggest that pain is grossly under-recognised and either untreated or under-treated, with only 1 in 4 patients receiving adequate pain relief. This impacts on all aspects of life, and results in needless suffering. Chronic pain is debilitating, and undermines mood, sleep patterns and physical and social functioning. It can suppress immune function, and can decrease the will to live in the terminally ill. Pain is the largest single barrier to recovery and rehabilitation. Early identification of pain, coupled with regular reassessment and evaluation of interventions, can greatly improve outcomes for successful rehabilitation and return to independence. People may be reluctant to admit to pain, for many reasons. These may include a fear of addiction or the side effects of medication, reluctance to complain or bother medical and nursing staff, an expectation that pain is normal and to be endured, or a desire to save medications in case the pain gets worse. Pain management is concerned with reducing suffering, and improving quality of life and functional status. It is essential that any pain management interventions are monitored and evaluated regularly. A variety of interventions may be trialled before the appropriate solution is found. Merely increasing drug dosages is not a solution. 237 At-Risk Populations The following populations are at most risk of receiving inadequate pain relief: • • • • • • • Children with cancer Women Minority groups The elderly People with impaired cognitive functioning Cancer patients HIV/AIDS sufferers Types of Pain There are several ways in which pain can be described and/or classified: • Duration – acute, subacute, chronic (>3 months) • Location – visceral (arising from visceral organs), somatic (arising from bone, joint, muscle, skin or connective tissue), neuropathic (abnormal processing of sensory input by peripheral or central nervous system) • Intensity – mild, moderate, severe, fluctuating • Aetiology – ischaemic, disease related, injury related • Type – dull, aching, gripping, gnawing, pressing, burning, pins and needles, sharp, stabbing, throbbing Assessment of Pain The identification and assessment of pain requires non-judgemental, active listening. Self-report of pain is more accurate than observation and/or vital signs. This is also true for people with cognitive impairments. Accept the patient’s perception of their pain – everyone experiences pain differently. There may be persistent pain underlying acute pain, and this needs to be identified in the initial assessment. Acute and persistent pain may require very different treatments and interventions. Persistent pain may be the main reason for presentation, with the acute episode often masking the underlying pain. Until the persistent pain problem is addressed, the patient will continue to present for treatment. Screen for pain, and if present, or likely to be present, complete an in-depth assessment. A thorough assessment of pain is essential to establish a baseline against which pain management can be measured. The assessment of acute pain is different from the assessment of chronic pain. Assessment should include questions about effects of pain on personal life, vocational and social functioning, and activities of daily living. It is important to gauge how pain, and the treatment, affect the whole person in their context. Pain should be assessed systematically, and classified according to likely origin. It is important to remember that pain may be in multiple locations, and due to different mechanisms and aetiologies. Assessments of pain should include: • • • • • • • 238 Intensity (1 of the most important elements) Location Quality Temporal characteristics Aggravating and alleviating factors Present pain regimen Pain management history • • • • Effects or impacts of pain Meaning of pain (patient’s perspective) Individual goals and expectations Physical examination/observation of site of pain Pain assessment should be cyclical – ask about the pain, accept and respect what you are told, introduce pain management strategies, ask again about the pain, and evaluate the efficacy of the interventions. Adjust interventions if necessary. Repeat cycle as required. Pain Assessment Tools Many different pain assessment tools have been developed for use. There are tools specifically for non-verbal infants and neonates, and others for young children. Language may be a barrier to pain assessment, and therefore tools are available which rely on pictograms e.g faces. An example of the tool used by MidCentral District Health Board is included in Appendix 2, with the kind permission of Judy Leader, Pain Nurse Specialist, MidCentral District Health Board. Psychosocial Patients are usually in considerable discomfort and distress. Consider age and level of distress in choice of analgesia. Morphine or pethidine may be required. The degree and route of analgesia and sedation will be determined by the experience of staff. Resources • Examples of Compliance: Pain assessment and Management. Joint Commission on Accreditation of Healthcare Organisations, 2002 • Approaches to Pain Management. An Essential Guide for Clinical Leaders. Joint Commission on Accreditation of Healthcare Organisations, 2003 • Special Feature: Pain, pg 68-87, in Chartbook on Trends in the Health of Americans. Health, United States, 2006 • Pain Clinical Manual. 2nd Edition. Margo McCaffery, Chris Pasero, 1999 • Links to Pain Management sites : – www.painresourcecenter.com – www.cityofhope.org/PRC/pain_assessment.asp • Red and Yellow Flags • Questionnaires 239 240 Appendix 2 PHC Nursing Health Assessment Form Client’s full name: ©Primary Health Care Nursing Development Team MDHB 2007 NHI: Sign Date and time of assessment: STATEMENT – I agree to sharing my health assessment and care plan with other health care professionals involved in my care. I understand a copy of my records is available to me and that it is useful for me to share this with other health care professionals with whom I come into contact, this ensures they are informed of my health status and allows the material to be kept up to date. Informed consent Signed_________________________Print name_________________________Date_______ Copy kept by client All issues must be flagged H-Health Concern, RM - Risk Management, E - Education, R – Referral Complete all white areas. Complete grey areas as indicated necessary by white area responses. Biographical Data Preferred name & title Previously known as Also known as Current Address and domicile code Recent address changes Phones DOB Home Mobile Work Alternative contact Fax Email Age Gender / / Ethnicity / / Date / / Date / / Male Iwi Date Female Other Hapu Primary language Interpreter utilised New Zealand Resident No Community Card status Yes Country of birth GP/Primary health care provider Practice Address Phone Fax Primary Nurse Address Phone Fax Other health providers Name Service Ph Fax Name Service Ph Fax Name Service Ph Fax Name & status of: Next of kin Nominated contact person Representative Agent Address Phones – Home Work Mobile Participants to page signatures: Print name: ITEM Relationship to client: RESPONSE Flag PROMPTS/COMMENT Time taken to complete page_______________ 241 (client details populate electronically) (Affix client ID label here) Health Perception/Health Management Does the client have any allergies? Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) No (if no – complete grey area) Specify Effect Frequency of occurrence Therapy Health Perception/Health Management - Medic Alert Specify Client’s reason for accessing health care Assessment Screening Monitoring Treatment Referral – in Referral – out Specify Does patient generally enjoy good health? Yes Specify Health Perception/Health Management - Past Health Relevant childhood illnesses Yes No (if yes – complete grey area) Specify Onset/age/duration Initial & ongoing effects ITEM Participants to page signatures: RESPONSE PROMPTS/COMMENT Flag 2 Print name: Relationship to client: 242 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) Health Perception and Health Management - Past Health continued Therapies Relevant accidents / injuries Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Specify Onset/age/duration Initial & ongoing effects Therapies Active ACC/Accredited Provider claim Serious or lifelong illnesses Specify Onset/age/duration Initial & ongoing effects Therapies Hospitalisations/operations Specify Onset/age/duration Initial & ongoing effects Therapies Immunisations up to date Specify ITEM Participants to page signatures: RESPONSE PROMPTS/COMMENT Flag 3 Print name: Relationship to client: Time taken to complete page_______________ 243 (client details populate electronically) (Affix client ID label here) Health Perception and Health Management - Past Health continued Mental health concerns Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Specify Onset/age/duration Initial & ongoing effects Therapies Relevant family health history Eg: Osteoporosis, CVD, Diabetes, Asthma/Eczema, CVA Specify Health Perception and Health Management - Medication Is client taking medicines/health supplements prescribed, overcounter or other Yes No (if yes – complete grey area) Specify Present medication Prescribed overcounter/other Dose Frequency Client’s perception of what medication is for How long been taking This would have facility to grow or shrink and have ability to pre populate (paper version use medication record insert) Yes No (if yes – complete grey area) Yes No (if no – complete grey area) Blister pack utilised Yes No (if yes – complete grey area) ITEM RESPONSE Street drugs or IV use Specify Medication administration independent Specify Participants to page signatures: PROMPTS/COMMENT Flag 4 Print name: Relationship to client: 244 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) Health Perception and Health Management - Medication continued Adherence to medication regime Yes No (if no – complete grey area) Yes No (if no – complete grey area) Yes No (if yes – complete grey area) Yes No Signature: Yes No (if yes – complete grey area) Yes No Specify Medication administration technique appropriate Specify Has regular pharmacy Specify Signed permission to obtain pharmacy/GP printout (may use form) Requires medication review (eg for drug interactions) Specify ROLE RELATIONSHIP Relationships? N/A (if yes or no – complete grey area) Home: Social: Work: Concerns: Assistance required: D.A. Participants to page signatures: 5 Print name: Relationship to client: Time taken to complete page_______________ 245 (client details populate electronically) (Affix client ID label here) ITEM ROLE RELATIONSHIP continued RESPONSE PROMPTS/COMMENT Flag Determinants of Health Yes Housing Own Rental No N/A Other Number of bedrooms (if yes – complete grey area) Numbers residing Describe residence/ living situation Environmental hazard concerns Yes No N/A (if yes – complete grey area) Yes No N/A (if no – complete grey area) Yes No N/A (if yes or no – complete grey area) Yes No N/A (if yes or no – complete grey area) Yes No N/A (if yes or no – complete grey area) No N/A (if yes – complete grey area) Specify Utilities all available & utilised (heating, phone, sewage, electricity, water, gas) Specify Access to transport Specify Employment/retirement Specify Adequate Finances Specify WINZ/Budgeting Case manager Yes no Name: Organisation Education history of relevance Yes Specify Participants to page signatures: 6 Print name: Relationship to client: 246 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM COGNITION AND PERCEPTION RESPONSE PROMPTS/COMMENT Any speech concerns Yes No N/A (if yes – complete grey area) Yes No N/A (if yes – complete grey area) Yes No N/A (if yes – complete grey area) Flag Specify Date of onset Duration Causative factors Alleviating/modifying factors Any vision concerns Left eye right eye Specify Date of onset & duration Causative/alleviating/ modifying factors Last tested when/by Therapy/aids Any hearing concerns Left ear right ear Specify issues Date of onset & duration Causative/alleviating/ modifying factors Last tested when/by Therapy/aids Participants to page signatures: 7 Print name: Relationship to client: Time taken to complete page_______________ 247 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE COGNITION AND PERCEPTION continued Yes Learning style identified No PROMPTS/COMMENT N/A Flag (if yes – complete grey area) (visual, aural, kinaesthetic, other) Visual Aural Kinaesthetic Yes Is client alert & orientated – time person place Auditory No N/A (if no – complete grey area) Specify Date of onset & duration Precipitating/ causative factors Alleviating factors Therapy/aids Yes No Passive Yes No Is client emotionally stable N/A (if yes – complete grey area) Specify Co-operative Restive Anxious Date of onset & duration Precipitating/ Alleviating factors Therapy/aids Affect appropriate N/A (if no – complete grey area) Specify Low mood Elated Labile Date of onset & duration Precipitating/ Alleviating factors Therapy/aids Participants to page signatures: 8 Print name: Relationship to client: 248 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) COGNITION AND PERCEPTION continued ITEM Is client’s thought content reality based RESPONSE Yes No N/A PROMPTS/COMMENT (if no – complete grey area) Yes No N/A (if no – complete grey area) Yes No N/A (if no – complete grey area) Flag Specify Date of onset & duration Therapy/aids Is client’s thought content coherent Specify Date of onset & duration Therapy/aids Mini Mental Sate Examination required Mini Mental State Examination COGNITION AND PERCEPTION – Pain Yes Does client have any pain/discomfort Acute Persistent No (if yes – complete grey area) Cause Date &/or time of onset Duration & location Pain quality & score out of 10 1 10 Precipitating & modifying factors Behavioural &/or psychological response Management SELF PERCEPTION SELF CONCEPT PATTERN Does client communicate self concept concerns (body image, esteem, personal identity)? Participants to page signatures: Yes No (if yes – complete grey area) 9 Print name: Relationship to client: Time taken to complete page_______________ 249 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE PROMPTS/COMMENT SELF PERCEPTION SELF CONCEPT PATTERN continued Flag Specify Onset/age/duration Initial & ongoing effects Therapies VALUES BELIEFS Cultural belief pattern matters of note Yes No (if yes – complete grey area) Yes No (if yes or no – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes or no – complete grey area) Yes No (if yes or no – complete grey area) Specify SLEEP AND REST Does client have established sleeping routines? Specify Has indications of obstructive sleep apnoea “Sleep apnoea chart drops here” STRESS AND COPING Does the client have any major concerns or stress? Specify Onset triggers/duration Management /Therapy ACTIVITY and EXERCISE Specified daily leisure activities Specify Specified usual exercise activities Specify Participants to page signatures: 10 Print name: Relationship to client: 250 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM RESPONSE ACTIVITY and EXERCISE continued Changes to usual activities/exercise level PROMPTS/COMMENT Yes No (if yes – complete grey area) Yes No (if no – complete grey area) Flag Specify Activity & Exercise - Mobility Independent with all aspects of ADLs ADL Needs Assistance Dependent Reason/ Comments Staff/equipment required Mobilising Dressing Bathing / Showering Getting into / out of bath Getting into / out of bed Feeding Toileting Housework Transport Shopping Meal preparation Specify Is experiencing /concerned about falls Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) “Falls risk assessment comes up” Activity & Exercise - Cardiovascular Any heart/circulatory concerns Specify Onset & duration Precipitating factors Alleviating factors Participants to page signatures: 11 Print name: Relationship to client: Time taken to complete page_______________ 251 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Activity & Exercise – Cardiovascular continued Flag PROMPTS/COMMENT Therapy Cardiology client Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Provider details Pacemaker/internal defibrillator Specify Cardiovascular risk assessment required Specify Pulse BPM Pulse quality Normal BP position Capillary Refill Bounding Regular Irregular mmHg Brisk Sluggish Skin colour Dorsalis Pedis: Nil Left No Yes Site(s) Peripheral Oedema Onset: Right Waist circumference cm Thready BP position mmHg /secs Skin Temp: present: Site Warm absent: Right Lipids known No Cool Cold Left Yes Activity & Exercise - Respiratory Known respiratory condition/ current breathing concerns Yes No (if yes to any of the following 3 questions– complete grey area) Spirometry assessment required Respiratory action plan in place and viewed Specify Spirometry Required Date completed dd/mm/yy Participants to page signatures: 12 Print name: Relationship to client: 252 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Activity & Exercise - Respiratory continued Dyspnoea SOB at night Respiratory rate Irregular Onset /min Shallow Flag PROMPTS/COMMENT Crackles Regular Wheeze Duration Precipitating/Alleviating factors Therapy/Medications/Aids Use of necessary muscles No Cough No Productive Sputum No Yes Chest expansion Normal Abnormal Yes Yes Acute Non-productive Chronic Amount Colour & consistency Onset Duration Precipitating/Alleviating factors Therapy/Medications/Aids Cyanosis No Peak flow Current Yes SpO2 Best Yes Technique assesed No Yes Education required No Inhaler use No Yes Technique correct No Artifical airway No Yes Specify Smoker No Never Former Yes Roll own Filter Exposure to second hand smoke No Never Former Understanding of PF change No Duration Yes Yes Brand Yes Number/day Precipitating factors Participants to page signatures: 13 Print name: Relationship to client: Time taken to complete page_______________ 253 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Activity & Exercise - Respiratory continued Curent Cessations methods tried No Respiratory Action Plan Updated NUTRITION METABOLIC Diet and Fluids Any dietary concerns Yes Yes Flag PROMPTS/COMMENT Specify Developed No (if yes – complete grey area) 24 hour dietary recall taken Specify 24 hour recall (box has ability to grow) Usual serving size: Breakfast Lunch Dinner Snacks Fluids, usual daily intake: Coffee cups Alcohol No Yes High salt diet cups Tea cups Cola cups Water Specify: consumption/routine/amount Yes No Yes No Recent nausea/vomiting Recent unplanned weight gain / loss Weight No Specify Yes Height BMI NUTRITION METABOLIC - Oral Health Any oral health concerns Yes No (if yes to either question – complete grey area) Dentures or partial plate Specify concerns Specify dentures/partial plate / position Teeth: Own Last attended/when Oral mucosa intact Participants to page signatures: Dental Care: No Yes 14 Print name: Relationship to client: 254 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Flag PROMPTS/COMMENT NUTRITION METABOLIC continued Skin Yes No (if yes – complete grey area) Skin intact and free of concerns Yes No (if no – complete grey area) Lesions Pressure damage MRSA status known Specify Petechiae Dry Abrasions Rashes Moles Bruises Specify Yes Sun safety utilised fully Slip (if no – complete grey area) Slop Braden pressure area risk assessment required No Slap Pamphlett supplied Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Braden Risk Assessment form Wound assessment required Wound Assessment form Nail concerns Fingernails: Overgrown Specify Toenails: Overgrown Specify Infected Clubbing Infected Requires assistance NUTRITION METABOLIC - Diabetes Yes Known to have diabetes Participants to page signatures: Requires assistance No (if yes – complete grey area) 15 Print name: Relationship to client: Time taken to complete page_______________ 255 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Flag PROMPTS/COMMENT NUTRITION METABOLIC - Diabetes continued Type 1 Type 2 Gestational Advised & usual testing regime Year diagnosed Advised Usual Reason for difference SBGM technique Testing independent Testing dependant Usual blood glucose range mmol Current BGL HBA1c Time taken Date taken Fluctuations: Highs Specify Lows Specify Screening programmes attended Next due Yes Risk assessment for diabetes required Weight Loss Blurred vision Thrush Fatigue No Infections (if yes – complete grey area) Stress Polydipsia Nocturia NUTRITION METABOLIC - ELIMINATION– Urinary Yes No Any concerns with urination Polyuria (if yes – complete grey area) Specify Odour Concerns: Flow Nocturia Blood Leakage Pain Frequency Burning Onset /Duration Precipitating/Alleviating factors Therapy/Medications/Aids Urinalysis required Participants to page signatures: Yes No (if yes – complete grey area) 16 Print name: Relationship to client: 256 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM RESPONSE Flag PROMPTS/COMMENT NUTRITION METABOLIC – ELIMINATION – urinary continued Urinalysis: Normal Abnormal Result NUTRITION METABOLIC – ELIMINATION – Gastrointestinal Bowels Yes No Has usual bowel pattern (if yes – complete grey area) Specify Yes Any bowel concerns/recent changes to pattern No (if yes – complete grey area) Specify Diarrhoea Concerns: Pain Ostomy Urgency Straining Haemorrhoids Blood Constipation Onset/Duration Therapy/Medications/Aids Abdominal examination completed Yes No (if yes – complete grey area) No (if yes – complete grey area) Specify Bowel sounds: Present Absent SEXUALITY/REPRODUCTION - Female Yes Obstetric history Specify: Gravida Terminations Miscarriages Yes Cervical screening Enrolled on programme Etopic Para No Yes Stillbirth No Smears of note LMP Regular Live children Specify Date last Cx Post coital bleeding (if yes or no – complete grey area) Intermenstrual bleeding Irregular Post menopause Specify Participants to page signatures: 17 Print name: Relationship to client: Time taken to complete page_______________ 257 (client details populate electronically) (Affix client ID label here) ITEM RESPONSE PROMPTS/COMMENT SEXUALITY/REPRODUCTION – Female continued Yes No Potential of pregnancy Yes Pregnancy test required Result Positive (if yes to either – complete grey area) No Referral required Negative Flag To be repeated: No Yes Contraception Specify Contraception failure / lapse Yes Breast examination No (if yes – complete grey area) National Breast Screening Programme Year Private Mammography Year / / Nil exam Breast self examination / / Specify: SEXUALITY/REPRODUCTION - Male Yes Testicular examination/prostatic examination No (if yes – complete grey area) Date of last exam/examiner Nil exam Last PSA level TURP: No Erectile concerns Yes Year Yes No (if yes – complete grey area) Yes No (if yes – complete grey area) Specify Potential for STI Sexual history - Male & Female Regular relationship? No Yes How many partners in the last 6 months Unprotected Protected Opposite sex Oposite sex Same sex Same sex Sexual practices – Male & Female Condom use Sex toys Sex overseas Sex work No No No Always Usually Participants to page signatures: Yes Yes Yes Sometimes Never Sex with someone from overseas No Yes Client of sex worker No Yes Oral sex No Yes 18 Print name: Relationship to client: 258 Time taken to complete page_______________ (client details populate electronically) (Affix client ID label here) ITEM RESPONSE PROMPTS/COMMENT Flag SEXUALITY/REPRODUCTION continued History of presenting problems Male & Female Discharge/colour Pain Dysuria Smell/Odour Itch Rash Lumps Ulcers No symptoms Length of time with symptoms Regular partner Symptomatic partner Last unprotected sexual episode Casual partner Male Female STI history No Yes Specify Past HIV test No Hep B status Participants to page signatures: Yes date / / year 19 Print name: Relationship to client: Time taken to complete page_______________ 259 260 Appendix 3: Resources ACC tools that can help assessments are available at www.acc.co.nz/for providers/resources Printed patient material is available. Refer to the website http://www.acc.co.nz Free copies are available from Wickliffe Press by phoning 0800 226 440 ACC313M He kainga ahuru mo nga tamariki kei raro iho I te rima tau (A child safe home for under fives – Maori) ACC313S O se aiga saogalemu mo tamaiti e I lalo o le lima tausaga le matutua (A child safe home for under fives – Samoan) ACC334 Safe at play – A guide to making playgrounds safer for children ACC344 Safe at play – Making playgrounds safer for children (brochure) ACC380 Manual handling equipment list ACC388 How to handle cattle better ACC389 How to design better cattle yards ACC393 Reducing injuries in the rural environment – Instructor’s Resource ACC394 Reducing injuries in the rural environment – Trainee’s Resource ACC395 Managing and riding ATVs ACC397 Farm safety ACC401 Managing and driving tractors ACC402 Riding farm bikes ACC405 Preventing slips, trips and falls ACC507 Stepping out with confidence – tear-away pads for doctors and other health professionals ACC 516 ‘Alofa I lou alo, fa’amau lona fusipa’u o totonu o le ta’avale (Love your child, fasten their seatbelt while in the car – Samoan] ACC525 Helpful advice on managing your acute low back pain ACC591 Dental injuries ACC601 Clinical Guidelines – Acute Management Traumatic Brain Injury ACC614 Preventing poisoning – keeping children safe from poisons ACC615 Managing your sports injury – injury management ACC624 Cycle Safety – it’s a two way street ACC620 Handling heavy loads ACC898 Managing Soft Tissue Ankle Injuries – September 2002 ACC1002 A slip, trip or fall could really hurt your business 261 ACC1017 Are you building up to fall? (Construction) ACC1018 Will an all-terrain vehicle drive you off the farm? (Agricultural) ACC1022 Are you the sort of feller who lives dangerously? (Forestry) ACC1038 New Zealand Acute Low Back Pain Guide. Incorporating the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain ACC1041 Lifetime Rehabilitation Planning ACC1110 He aria I te takanga a nga tamariki nonohi (Preventing falls with under fives – Maori) ACC1111 Preventing falls in under fives ACC1174 How to manage hazards: for construction ACC1176 Training and supervision: for construction ACC1251 How to manage hazards: for seafood processing ACC1253 Training and Supervision: for seafood processing ACC1305 How to manage hazards: for forestry ACC1307 Training and supervision: for forestry ACC1388 Caring for your Plaster Cast ACC1390 Caring for your stitches ACC1409 Sideline Concussion Check ACC1631 Acute Low Back Pain screening questionnaire ACC1945 Don’t Take Back Pain Lying Down – Self management guide to acute low back pain ACC2172 Knowing about your low back pain ACC2373 Practical Techniques in Injury Management: Casts and Splints ACC4046 The Management of Burns and Scalds in Primary Care 2007 ACC Review: Issue 2 August 2003 – Acute Soft Tissue Ankle Injuries Assistance after a hearing loss injury (fact sheet) (PDF 48K) Caring for your child after an injury to the head (fact sheet) FSENT01 Help to speed your recovery (fact Sheet) FSREB01 Making a rehabilitation plan (fact sheet) FSENT02 Travel to treatment (fact sheet) FSREB14 Helping your employee return to work (fact sheet) FSVI01 Vocational Independence Assessment (fact sheet) Ministry of Health Immunisation Handbook 2006 Ministry of Health Code 1424 Spiders in New Zealand – What to look out for and keeping yourself safe What to do after an injury to the head (fact sheet) 262 May 2008 EDITION Prepared by ACC P O Box 242, Wellington, New Zealand www.acc.co.nz ACC Provider Helpline: 0800 222 070 ACC Enquiry Service Centre: 0800 101 996 May 2008 Nursing Treatment Profiles m ay 2 0 0 8 Nursing Treatment Profile ACC4593 • ISBN: 978–0–478–31425–0 • printed May 2008
