Emergency

Nursing
BSN – 4E Group 3

Mae Valerie Bermudez

Naldy John Delos Santos
Stephanie Marie Lim
Kathreen Glaiza Mendoza
Michael Santos
Rizza Faith Sasi
Denise Marie Villanueva
Thoracente
sis
 Thoracentesis (THOR-a-sen-TE-sis) is a procedure to
remove excess fluid in the space between the lungs
and the chest wall.
 This space is called the pleural space.
 Normally, the pleural space is filled with a small
amount of fluid about 4 teaspoons full.
 But some conditions, such as heart
failure, lung infections, and tumors,
can cause more fluid to build up.
 When this happens, it’s called a
pleural effusion.
 A lot of extra fluid can press on the
lungs, making it hard to breathe.
 Overview
 Thoracentesis is done to find the cause of a
pleural effusion.
 It also may be done to help you breathe easier.
 During the procedure, your doctor inserts a
thin needle or plastic tube into the pleural
space and draws out the excess fluid.
 Usually, doctors take only the amount of fluid needed to find
the cause of the pleural effusion.
 However, if there's a lot of fluid, they may
take more.
 This helps the lungs expand and take in more air, which
allows you to breathe easier.
 After the fluid is removed from your
chest, it's sent for testing.
 Once the cause of the pleural effusion is
known, your doctor will plan treatment.
 For example, if an infection is causing the
excess fluid, you may be given antibiotics
to fight the infection.
 If the cause is heart failure, you will be
treated for that condition.
 Thoracentesis usually takes 10 to 15
minutes.
 It may take longer if there's a lot of fluid
in the pleural space.
 You will be watched for up to a few hours
after the procedure for complications.
 Outlook
 The procedure usually doesn't
cause serious problems, but
some risks are involved.

• These include pneumothorax (noo-mo-

THOR-aks), or collapsed lung; pain,
bleeding, bruising, or infection where the
needle or tube was inserted; and liver or
spleen injury (very rare).
• Most of these
complications get better on
their own, or they're easily
treated.
Who Needs Thoracentesis?
 You may need thoracentesis if you have a
pleural effusion.
 A pleural effusion is the buildup of excess
fluid in the pleural space (the space
between the lungs and chest wall).
 Thoracentesis helps find the cause of the
pleural effusion.
 It also may be done to help you
breathe easier, if there's a lot of
fluid in the pleural space.
 The most common cause of a
pleural effusion is heart failure.
 This is a condition in which the
heart can't pump enough blood to
the body.

 Other causes include lung cancer,

tumors, pneumonia, tuberculosis,
pulmonary embolism, and other lung
infections.
 Asbestosis, sarcoidosis, and
reactions to some drugs also can
Diagnosing a Pleural Effusion
 A pleural effusion is diagnosed based on your

medical history, a physical exam, and test results.

Medical History
 Your doctor will ask

 about your symptoms,

 like trouble breathing, coughing, and

hiccups.
 Other things your doctor may ask about

include whether you've ever:

 Had heart disease

 Smoked

 Traveled to places where you may have

been exposed to tuberculosis

 Had a job that exposed you to asbestos
Physical Exam
 Your doctor will listen

to your breathing with a

stethoscope and tap
lightly on your chest.
 If you have a pleural effusion, your

breathing may sound muffled.

 There also may be a dull sound when

your doctor taps on your chest.

 Diagnostic Tests
 Your doctor may use
one or more of the
following tests to diagnose
a pleural effusion.

1.Chest x ray.
This test takes pictures of your heart and lungs.
It may show air or fluid in the pleural space.
It also may show what's causing the pleural
effusion, such as pneumonia or a lung tumor.
To get more detailed pictures, the x rays may
be done while you're in different positions.
2. Ultrasound.
 This test uses sound waves
to create pictures of your lungs.
 It may show where fluid is in
your chest.
 Sometimes it's used to find
the right place to insert the needle
or tube for thoracentesis.
3. Computed tomography (CT)
scan.
This test provides a computer-
generated picture of the
lungs that can show pockets
of fluid.
It may show fluid when a chest x
ray doesn't.
It also may show signs of
 Before Thoracentesis
 Before thoracentesis, your
doctor will talk to you
about the procedure and
how to prepare for it.
 Tell your doctor what medicines you're taking,
about any previous bleeding problems, and
about allergies to medicines or latex.
 No special preparations are needed before
thoracentesis.
 During Thoracentesis
 Thoracentesis is done at a doctor's office
or hospital.
 The entire procedure (including
preparation) usually takes 10 to 15
minutes, but the needle or tube is in
your chest for only a few minutes during
that time.
 If there's a lot of fluid, the procedure
may take up to 45 minutes.
 You will sit on the edge of a chair or exam table, lean
forward, and rest your arms on a table.
 Your doctor will tell you not to move, cough, or breathe
deeply once the procedure begins.
 He or she cleans the area of your skin where the needle
or tube will be inserted and injects medicine to numb
the area.
 You may feel some stinging at this time.
 Your doctor then inserts the needle
or tube between your ribs and into
the pleural space (the area between
the lungs and chest wall).
 You may feel some discomfort and
pressure at this time.
 Your doctor may use ultrasound to
find the right place to insert the
needle or tube.

•He or she then draws out the excess fluid

around your lungs using the needle or tube.
•You may feel like coughing, and you may feel
some chest pain.
•If a lot of fluid is removed, your lungs will have
more room to fill with air as the fluid is drawn
out.
•This can make it easier to breathe.
 After Thoracentesis
 After the procedure, you will be
monitored until your blood pressure,
pulse, and breathing are stable.
 If the procedure was done at the
bedside, you will remain in your hospital
room.
 If the procedure was performed on an
outpatient basis, you will be discharged
to your home, unless your physician
decides otherwise.

•If the procedure was performed on an

outpatient basis, you should plan to have
another person drive you home.
•The dressing over the puncture site will be
monitored for bleeding or other drainage.
 You will be positioned in a side-lying position with
the unaffected side down for an hour or longer.
 You may have a chest x-ray performed after the
procedure.
 When the recovery period is over, you may resume
your usual diet and activities unless your physician
advises you differently.
 Notify your physician to report any of the following:

1.fever and/or chills

2.redness, swelling, or bleeding or other drainage
from the puncture site
3.difficulty breathing
4.Your physician may give you additional or
alternate instructions after the procedure,
depending on your particular situation.
Paracentesis
Procedure Name: Paracentesis
Description:
 It is the removal of fluid(ascites) from the

peritoneal cavity through a puncture or a small

surgical incision through the abdominal wall
under sterile conditions.
Synonyms:
 Abdominal Paracentesis; Ascites Fluid Tap

Procedure Commonly Includes:

 At the bedside, physician introduces a needle into

the peritoneal space of a patient with free ascites,

and samples the fluid for diagnostic and/or
therapeutic purposes.
 Indications
 patients with new onset of
ascites
 ascites fluid of unknown
etiology
 patients with clinically
suspected ascites fluid infections
(abdominal pain, unexplained fever,
leukocytosis, declining mental status)
 Lastly therapeutic paracentesis is indicated
when ascites fluid has accumulated enough
to cause respiratory compromise, abdominal
pain, or worsening of existing inguinal or
umbilical hernias.
 Contraindications
 Severe coagulopathy not correctable by
vitamin K, fresh frozen plasma, etc;
inability of physician to demonstrate
ascites fluid on physical examination; lack
of patient cooperation.
 Recent literature
suggests the following
factors are not
contraindications for
paracentesis: morbid obesity, low grade
coagulopathy, multiple abdominal surgical
scars, and bacteremia.
 Patient Preparation
 Technique and risks of the procedure
are explained.
 Premedications (eg, sedatives or
narcotics) are not routinely required.
 Laboratory requisitions are completed in
advance to avoid delay in fluid
processing later.

•Prothrombin and partial thromboplastin

times prior to paracentesis are ordered at
physician discretion (some elect to transfuse
fresh frozen plasma immediately prior to
procedure if PT/PTT are prolonged).
 Preprocedure
 Check for signed consent form
 Prepare the patient by providing the necessary
information and instructions
 Instruct the patient to void
 Gather appropriate sterile equipment and collection
receptacles
 Place the patient in upright position on the
edge of the bed or in a chair w/ feet supported
on a stool.
 Fowler's position should be used by the patient
confined to bed.
 Place the sphygmomanometer cuff around
patient's arm.
 Procedure
 The physician, using aseptic technique, inserts the
trocar through a puncture below the umbilicus.
 The trocar or needle is connected to a drainage tube, the
end of w/c is inserted into a collecting receptacle.
 Help the patient maintain position throughout the
procedure.
 Measure and record blood pressure at frequent intervals
throughout the procedure.
 Monitor the patient closely for signs of vascular
collapse: pallor, increased pulse rate, or decreased
blood pressure.
 Postprocedure
 Return patient to bed or to a comfortable sitting postion
 Measure, describe, and record the fluid collected.
 Label samples of fluid and send to laboratory.
 Monitor vital signs every 15 min for 1h, every 30 min for 2h,
every hour for 2h, and then every 4h.
 Measure the patient's temperature.
 Assess for hypovolemia, electrolyte shifts, changes in mental
status and encephalopathy.
 When taking vital signs, check puncture site for leakage or bleeding.
 Provide patient teaching regarding need to monitor for
bleeding or excessive drainage from puncture site.
scess Incision and Drainage
 Abscesses are localized infections of tissue
marked by a collection of pus surrounded by
inflamed tissue.
 Abscesses may be found in any area of the body,
but most abscesses presenting for urgent
attention are found on the extremities, buttocks,
breast, perianal area, or from a hair follicle.

Abscesses begin when the normal skin

barrier is breached, and microorganisms
invade the underlying tissues.
Causative organisms commonly include
Streptococcus, Staphylococcus, enteric
bacteria (perianal abscesses), or a
combination of anaerobic and gram-
negative organisms.
 Abscess resolve by drainage.
Smaller (<5mm in diameter)
abscesses may resolve to
conservative measures (warm
soaks) to promote drainage.

• Larger abscesses will

require incision to drain
them, as the increased
inflammation, pus
collection, and walling off
of the abscess cavity
diminish the effectiveness
of conservative measures.
Indications
Abscess on the skin which is
palpable
Contraindications
 Extremely large abscesses which require
extensive incision, debridement, or irrigation
(best done in OR)
 Deep abscesses in very sensitive areas
(supralevator, ischiorectal, perirectal) which
require a general anesthetic to obtain proper
exposure
 Palmar space abscesses, or abscesses in the
deep plantar spaces
 Abscesses in the nasolabial folds (may drain
to sphenoid sinus, causing a septic phlebitis)
 Materials
 Universal precautions materials
 1% or 2% lidocaine WITH epinephrine for
local anesthesia, 10 cc syringe and 25
gauge needle for infiltration
 Skin prep solution
 #11 scalpel blade with handle
 Draping
 Gauze
 Hemostat, scissors, packing (plain or
iodoform, 1/2”)
 Tape
 Culture swab
 Preprocedure Education
 Obtain informed consent
 Inform the patient of potential
severe complications and their
treatment
 Explain the steps of the
procedure, including the not
insignificant pain associated
with anesthetic infiltration
 Explain necessity for follow-up,
including packing change or
removal
 Procedure
 Use universal precautions
 Cleanse site over abscess with
skin prep
 Drape to create a sterile field
 Infiltrate local anesthetic, allow
2-3 minutes for anesthetic to
take effect
 Incise widely over abscess with
the #11 blade, cutting through
the skin into the abscess cavity.
Follow skin fold lines whenever
able while making the incision
 Allow the pus to drain, using the
gauzes to soak up drainage and
blood. Use culture swab to take
culture of abscess contents,
swabbing inside the abscess
cavity
 Use the hemostat to gently
explore the abscess cavity to
break up any loculations
within the abscess
 Using the packing strip, pack the
abscess cavity
 Place gauze dressing over
wound, and tape in place
 Postprocedure
 Much of the pain around an abscess will be gone
after the surgery.
 Healing is usually very rapid.
 After the drainage tube is removed, antibiotics may
be continued for several days.
 Applying heat and keeping the affected area
elevated may help relieve inflammation.
Complicatio Prevention Management
n
Insufficient Remember that the Do a field block;
anesthesia tissue around an use sufficient
abscess is acidotic, quantity of
and local anesthetic anesthetic; allow
loses effectiveness time for
in acidotic tissues anesthetic effect

No drainage Localize site of Extend incision

incision by deeper or wider
palpation as needed
Drainage is Abscess was an Express all
sebaceous inflamed sebaceous material, break
material cyst up sac with
hemostat, pack
open as with an
Surgical Excision
 DEFINITION
Surgical excision is the removal of tissue
by a doctor or surgeon using a scalpel
(sharp knife) or other cutting instrument.
Why do skin lesions have to be excised?
 A common reason why skin lesions are excised, is

to fully remove skin cancers such as basal cell

carcinoma, squamous cell carcinoma or melanoma.
If the cancer is not cut out it may spread to the
surrounding skin and to other parts of the body
(metastasise).
 Other reasons that skin lesions are excised include

cosmetic appearance, to remove an inflamed cyst,

or recurrent infection.
What is involved in excision of a skin lesion?
 Your dermatologist will explain to you why the skin lesion
needs excision and the procedure involved.
 You may have to sign a consent form to indicate that you
consent to the surgical procedure.

•Tell your doctor if you are taking any

medication (particularly aspirin or warfarin,
which could make you bleed more), or if
you have any allergies or medical
conditions.
•Remember, to tell your doctor about any
herbal remedies as a number of these can
 The most common type of excision is an
elliptical excision.
 The ellipse is designed so that the resulting scar
runs parallel with existing skin creases.
 This ensures that the scar is as narrow and short
as possible.

• The area to be excised is marked with a

coloured pen.
• The dermatologist will then cut around
and under the lesion with a scalpel and
sharp scissors so that it is completely
removed.
• The lesion is placed in formalin ready to
 Here, a pathologist will
examine the specimen and
provide your doctor with a
report a few days later.
 There may be some bleeding
in the area from where the
lesion has been removed.
 The doctor may coagulate
the blood vessels with a
diathermy.
 This can make a hissing
sound and a burning smell.
 The edges of the ellipse will then be sewn together to
make a thin suture line.
 There may be two layers of sutures (stitches) ­ a layer
underneath that is absorbable and a layer of sutures on
the surface which will need to be removed in 4-14 days.

•Occasionally special skin glue is used to

join the edges together, instead of
sutures.
•A dressing may be applied and
instructions should be given on how to
care for your wound and when to get
How do I look after the wound following skin excision?
 Your wound may be tender 1-2 hours after the excision

when the local anaesthetic wears off.

 Leave the dressing in place for 24 hours or as advised by

your dermatologist.

•Avoid strenuous exertion and

stretching of the area until the
stitches are removed and for some
time afterwards.
•If there is any bleeding, press on the
wound firmly with a folded towel
without looking at it for 20 minutes.
 Keep the wound dry for 48 hours. You can then
gently wash and dry the wound.
 If the wound becomes red or very painful, consult
your dermatologist - it could be infected.

• The scar will

initially be red and
raised but usually
reduces in colour
and size over several
months.
Open and Closed Wounds
 An open wound is a break in the
skin’s surface resulting in external
bleeding.

 It may allow bacteria to enter the

body, causing an infection.
1. Abrasion
 The top layer of
skin is removed,
with little or no
blood loss.
2. Laceration
 Is cut skin with
jagged, irregular
edges.

 Caused by a
forceful tearing
of skin tissue.
3. Incisions
 Have smooth edges
and resemble a
surgical or paper cut.
4. Punctures
 Usually deep,
narrow wounds in
the skin and
underlying organs
such as stab from
a nail or a knife.
5. Avulsion
 A piece of skin is
torn loose and is
hanging from the
body or completely
removed.
6. Amputation
 Involves the cutting
or tearing off of a
body part.
 Protect yourself against disease.
 Expose the wound by removing or
cutting away the clothing to find the
source if bleeding.
 Control the bleeding by using direct
pressure.
 If needed, use other method.
 Scrub your hands.
 Expose the wound.
 Clean the wound (next slide).
 Remove small objects not flushed out
with sterile tweezers.
 If bleeding restarts, apply direct
pressure over the wound.
For a shallow wound:
 Wash inside the wound with soap and

water.
 Flush the wound with running water.

For a wound with high risk of infection:

 Seek medical care.

 Clean the wounds as best as you can.

 For small wound:
 Cover it with a thin layer of antibiotic ointment.
 Cover the wound with sterile dressing.
 If a wound bleeds after dressing has been applied and the dressing
becomes stuck, leave it on as long as the wound is healing.
 If dressing becomes wet or dirty, change it.
When to Seek Medical Care:
 Embedded foreign material
 Animal and human bites
 Puncture wounds
 Large or deep wounds
 Wound where edges do not come
together
 Visible bone, joint, muscle, fat, or
tendons
 Happens when a blunt object
strikes the body.

 The skin is not broken, but tissue

and blood vessels beneath the
skin’s surface are crushed, causing
bleeding within a confined area.
1. Contusions
 more commonly
known as bruises,
caused by blunt force
trauma that damages
tissue under the skin.
2. Hematomas
 also called blood
tumors, caused by
damage to a blood
vessel that in turn
causes blood to
collect under the
skin.
 Control bleeding by applying an ice
pack over the area >20 minutes
 For extremities, apply an elastic
bandage for compression
 Check for a possible fracture
 Elevate an injured extremity to
decrease the pain and swelling
 Bone Fractures
• A broken bone (fracture) occurs when a force
exerted against bone is stronger than the bone
can structurally withstand.

• Bones are a form of connective tissue,

reinforced with calcium and bone cells.

• Bones have a softer centre, called marrow,

where blood cells are made.

• The main functions of the skeleton include

support, movement and protection of
vulnerable internal organs.
 There are different types of bone fractures that vary in
severity.
 Factors that influence severity include the degree and
direction of the force, the particular bone involved,
and the person's age and general health.
 Common sites for bone fractures include the wrist,
ankle and hip.

• Hip fractures occur most often in elderly

people.
• Broken bones take around four to eight
weeks to heal, depending on the age, health
of the individual, and the type of break.
 Symptoms
The symptoms of a bone fracture depend on
the particular bone and the severity of the
injury, but may include:

 Pain, with sweating and a pale face

 Swelling
 Bruising
 Deformity
 Inability to use the limb.
1. Greenstick
fracture
 the bone sustains
a small, slender
crack. This type of
fracture is more
common in
children, due to
the comparative
flexibility of their
bones.
2.Comminuted
fracture
 the bone is

shattered into
small pieces. This
type of
complicated
fracture tends to
heal at a slower
rate.
3.Simple fracture
 The broken bone

hasn't pierced the

skin.
4. Compound
fracture
 The broken bone

juts through the

skin, or a wound
leads to the
fracture site. The
risk of infection is
higher with this
type of fracture.
5. Pathological
fracture
 bones weakened
by various
diseases (such as
osteoporosis or
cancer) tend to
break with very
little force.
6. Avulsion fracture
 muscles are anchored to
bone with tendons, a
type of connective tissue.
Powerful muscle
contractions can wrench
the tendon free, and pull
out pieces of bone. This
type of fracture is more
common in the knee and
shoulder joints.
7.Compression fracture
 occurs when two bones are
forced against each other.
The bones of the spine,
called vertebrae, are prone
to this type of fracture.
Elderly people, particularly
those with osteoporosis, are
at increased risk.
Recognizing Fractures
 It may be difficult to tell if a bone is broken.

When in doubt, treat the injury as a fracture.

Assess for D-O-T-S
 Deformity
 Open wound
 Tenderness
 Swelling
 Care for Fractures:
 Expose and examine the injury site.
 Bandage any open wound.

 Splint the injured area.

 Apply ice or cold pack.

 Seek medical care or Call 9-1-1.

 Transport victim if necessary.

Reduction of Fractures
Reduction
 It is the positioning a bone or bones to their normal
position after a fracture or dislocation.
 The goals of a reduction are to restore position
(alignment, rotation, and length) to the bone or joint,
to decrease pain, to prevent later deformity, and to
encourage healing and normal use of the bone and
limb.

In the case of a fracture, it is also important

for the bone ends to meet correctly
(apposition).
If a fracture is described as "non-displaced" or
in "anatomic position," no reduction
maneuver to improve position can be
performed, since the fracture is already in
  Also, this is the correct approximation of the broken portions
(fragments) of the bone. There are two types of reduction namely:

Closed Reduction (External Fixation)

• In closed reduction (external fixation), the
fracture is realigned to normal position
through external manipulation of the part.
• Closed reduction is accomplished under x-
ray control to be certain that the fracture is
in correct position.
• Closed reduction is the method by which
closed fractures are reduced most
commonly.
• Then the alignment is maintained by
immobilizing the part by either of two
 (1)  A plaster cast may be applied to hold the fragments in
correct alignment after a fracture has been reduced.
 (2)  The other method of external fixation is the application
of skeletal traction by means of special pins or wire inserted
through the soft tissue into bone that is distal to the
fracture.

Open Reduction (Internal Fixation).

• This is the reduction of a fracture by
the application of mechanical devices
(see figure 5-1) (screws, plates and
screws, pins, intramedullary nails)
through an incision directly to the bone.
EFFECTS OF CLOSED REDUCTION FRACTURE
 With this procedure, the bone should heal in a

normal position and the patient will regain the use of

the bone and the limb it serves.
 The pain from the broken bone will be relieved with

this procedure.
CANDIDATES FOR CLOSED REDUCTION FRACTURE
 A closed reduction procedure is recommended if

your bone is broken in one place and has not broken

the skin and you do not need plates, pins, or screws
put in the bone to help hold it in place.
THE PROCEDURE:
 Closed reduction of a fracture involves

manipulation of a fracture or dislocation without

open surgery in order to realign broken or
dislocated bones so that the ends meet, thereby
facilitating the healing process.

• It is the most common type of

fracture treatment, because most
broken bones can heal
successfully once they have been
repositioned and a cast has been
applied to keep the broken ends in
proper position while they heal.
RECOVERY
 A hospital stay is not necessary.

 You may go home later in the day

depending on how you are doing.

It is likely that you may have a

splint, dressing or cast to help keep
the bone in place during the
healing process.
Talk to your health care provider
and ask what steps you should take
and when you should return for a
check-up.
 RISKS
 Aside from the risks of general
anesthesia, there are other
complications with this procedure.
 For one, the bone may grow together in
a different way than it was originally
and may not be perfectly lined up.

There may also be a loss of

feeling in the area of the break if
a nerve is damaged.
And if an artery is near the
fracture, it could be damaged too.
 Once the correct position has been
attained, the affected area is put into a
cast or traction to ensure immobility.
 Sedation or some form of anesthesia is
usually used during the procedure.
BENEFITS
 You might receive the following benefits.

The doctors cannot guarantee you will

achieve any of these benefits. Only you
can decide if the benefits are worth the
risk. Results depend upon the extent of
damage to the bone and the location of the
bone itself; if successful, there may be:
 Complete healing
 Reduced pain
 Improved alignment of the fracture fragments
 This procedure is used to repair broken
fragments by means of pins, nails, and screws,
or with plates and screws, through an open
wound.
 A blind method of fixation may be used by
applying a short nail (Smith-Petersen) or a long
nail (Kuntscher or Lottes) through the bone
without opening the fracture site.

• Internal fixation is used when a

satisfactory closed reduction cannot be
obtained or maintained or when soft parts
are situated between the fractured
fragments.
• Whenever possible, this operation is done
before swelling has occurred or after
swelling has subsided. It is not routinely
 An open reduction or open reduction, internal
fixation (ORIF) is done when a closed reduction
is not possible or when the fracture is
complicated by a wound.
 This is an in-patient or outpatient surgical
procedure performed in the operating room.
 An incision is made over the fracture, wounds
are cleaned, and the fracture position is
corrected with pressure.
 Sometimes the reduced position is maintained
with orthopedic hardware such as screws,
plates and rods, placed through or around the
fracture fragments (internal fixation).
  An external fixator device may be
used to maintain position.
 The fixator is composed of pins or
rods through the skin and bone, and
the free end of the rods are then
attached to a long bar on the
outside of the skin.

•This device can allow for early motion of the joints

above and/or below the fracture.
•It is always eventually removed, often in the
physician's office, while internal hardware may be
left in place.
•If internal hardware is to be removed, another
surgical procedure is required.
 The outcome of a closed or open reduction depends on the
type of injury and the treatment needed to maintain the
reduction and the healing of bone and supporting tissue (joint
capsule, tendons, ligaments, and muscles).
 Generally, fractures and dislocations can be re-positioned
(reduced) but this may not always be a simple, straightforward
procedure.

•Once the reduction is complete,

the healing phase may involve
treatment over several months.
•Any complication regarding
nerves or blood vessels will delay
healing and may contribute to a
poor outcome.
  For fractures that involve joints (intra-articular
fractures), the more comminuted (broken into
multiple fracture pieces) the joint surface and
the greater joint surface deformity present
after the fracture has healed, the worse the
prognosis for the development of late post-
traumatic arthritis of the joint.

• Fractures that do not involve joints but that

heal with significant deformity change
biomechanics of the limb and may lead to
post-traumatic arthritis of adjacent joints.
  Some bones such as those in the wrist (scaphoid
and lunate) and hip (femoral head) have a poor
blood supply to begin with and historically do not
heal well.
 Individuals with loose tissue (laxity) have a
higher incidence of recurrent dislocation, as
do those with anatomical variations such as
tilted kneecaps (patellar misalignment).
 Joints that remain dislocated for a long time
have a less successful outcome.
 Bone
Grafting
 This procedure involves exposure of the
fractured fragments, attachment of healthy
bone onto the bone fragments, and insertion
of screws through holes made in the graft
and into the cortex of the fragments.

• The amount of grafting material

used and the type of graft done
generally depends on the location
of the non-united bone, the
condition of the ends of the
fragments, and the preference of
the surgeon.
The procedure may be used in the following
circumstances:
(1)  To fill cavities or defects resulting from
cysts, tumors, or other causes.
(2)  To bridge joints and thereby provide
arthrodesis.
(3)  To bridge major defects or establish the
continuity of a long bone.
(4)  To promote union or fill defects in
delayed union, malunion, fresh fractures,
or osteotomies.
 Operative Procedure
(1)  The skin overlying the fractured bone is
incised and the scar tissue is excised, as in
open reduction.
 To encourage healing, the sclerosed bone may

be drilled or removed to stimulate granulation

tissue foundation.
(2)  The graft is obtained, and the affected
fragments are prepared to suit the graft.
 To form a bed for an onlay graft, the

periosteum and a portion of the outer cortex

are removed from the fragmented ends of the
bone.
 To perform an inlay or sliding graft, a special
slot is made in the bone fragments for the
reception of the graft.
 Occasionally, a sliding graft is used for tibial

fractures.
 The graft is cut from the proximal fragment of

the fractured bone and is slid into the prepared

bed over the distal fragment of the bone.
(3)  To obtain an inlay graft from the tibia, a
curved incision is made along the anteromedial
surface of the tibia, with its convexity to the
medial side.
 The periosteum is incised and reflected with an

osteotome.
 The graft is outlined with drill holes, and removed with
an electric oscillating bone saw that has a double
blade.
 A fracture of the entire thickness of the donor bone

may occur if the osteotomy is not outlined by drill

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

graft and into the cortex of the bone's fragments. In

some cases, bone chips are laid over the fragments to
be united.
 (5)  A cancellous graft consists of spongy bone, usually
taken from the crest or wing of the ilium.
 Depending on the position of the patient, the anterior or
posterior third of the ilium is used.
 Exposure of the ilium is relatively easy, but considerable
bleeding may occur.
 An incision is made along the subcutaneous border of the
iliac crest.
 The muscles on the outer table of the ilium are elevated. If
chip grafts are required, they are removed with an
osteotome parallel to the crest of the ilium. After removal of
the crest, the cancellous bone maybe obtained by curetting
the cancellous space between the two intact cortices.
 (6)  The wounds are closed in layers and dressings applied.
A plaster casing may be applied to the fractured extremity.
Chest Thoracostomy Tube
DESCRIPTION
 Chest tubes are inserted to drain blood, fluid, or air

and to allow the lungs to fully expand.

 The tube is placed between the ribs and into the
space between the inner lining and the outer
lining of the lung (pleural space).
 The area where the tube will be inserted is numbed

(local anesthesia).
 Sometimes sedation is also used.
 The chest tube is inserted through an incision

between the ribs into the chest and is connected to

a bottle or canister that contains sterile water.
 Suction is attached to the system for drainage.
 A stitch (suture) and adhesive tape keep the
tube in place.
 The chest tube usually stays in place until the
x-rays show that all the blood, fluid, or air has
drained from the chest and the lung has fully
re-expanded.
 When the chest tube is no longer needed, it
can be easily removed.
 Most people don't need medications to sedate
or numb them while the chest tube is removed.
 Antibiotics may be used to prevent or
treat infection.
 In certain people, the chest tube may
be inserted using a minimally invasive
technique guided by x-ray.
 Sometimes chest tubes are placed during
major lung or heart surgery while the
person is under general anesthesia.
Why the Procedure is performed?
 Chest tubes are used to treat

conditions that can cause the lung to

collapse, such as:
 Air leaks from the lung into the chest

(pneumothorax)

• Bleeding into the chest

(hemothorax)
• After surgery or trauma in the
chest (pneumothorax or
hemothorax)
• Lung abscesses or pus in the
chest (empyema).
INDICATIONS
 Tube thoracostomy is indicated for

pneumothorax, hemothorax, pleural effusion,

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

CONTRAINDICATIONS
 Tube thoracostomy is contraindicated in the

absence of a pleural space (pleural symphysis).

 Coagulopathy is a relative contraindication in

elective settings.
MATERIALS
 1. Chest tube; OR Fuhrman catheter

 2. Chest tube suction unit (PleurevacR), tubing, wall

suction hookup
 3. Chest tube tray to include scalpel blade and

handle, large Kelly clamps, needle driver, scissors

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

 Tape, gauze

 2% lidocaine with epinephrine, 20 cc syringe, 23-

gauge needle for infiltration

 Sterile prep solution; Mask, gown and gloves
PREPROCEDURE PATIENT EDUCATION
 1. Obtain informed consent

 2. Inform the patient of the possibility of

major complications and their treatment

 3. Explain the major steps of the

procedure, and necessity for repeated

chest radiographs
 PROCEDURE
1. Examine the patient and assess need for placement of a
thoracostomy tube. Obtain pre-procedure chest X-ray
 VERIFY SITE OF INSERTION!!!!!!
2. Select site for insertion: mid-axillary line, between 4th and
5th ribs…this is usually on a line lateral to the nipple
3. Don mask, gown and gloves;
4.Prep and drape area of insertion. Have patient place
ipsilateral arm over head to “open up” ribs
5. Widely anesthetize area of insertion with the 2%
lidocaine. Infiltrate skin, muscle tissues, and right down to
pleura
 CHEST TUBE INSERTION  
 After infiltrating insertion site with local anesthetic,
make a 3-4 cm incision through skin and
subcutaneous tissues between the 4th and 5th ribs,
parallel to the rib margins
INCISING THE CHEST WALL
INSERTION 
 -Continue incision through the intercostal muscles,
and right down to the pleura
 -Insert Kelly clamp through the pleura and open
the jaws widely, again parallel to the direction of
the ribs (this “creates” a pneumothorax, and
allows the lung to fall away from the chest wall
somewhat
 OPENING THE INCISION WITH KELLY
INSERTION 

 Insert finger through your incision and into the

thoracic cavity.
 Make sure you are feeling lung (or empty space) and
not liver or spleen
 -Grasp end of chest tube with the Kelly forcep
(convex angle towards ribs), and insert chest tube
through the hole you have made in the pleura.
 After tube has entered thoracic cavity, remove
Kelly, and manually advance the tube in
 USING A KELLY TO GUIDE INSERTION
INSERTION 

 -Clamp outer tube end with Kelly

 -Suture and tape tube in place
 -Attach tube to suction unit
 -Obtain post procedure chest Xray for
placement; Tube may need to be
advanced or withdrawn slightly
 COMPLICATIONS, PREVENTION, AND
MANAGEMENT  
1. Puncture of liver or spleen. This is entirely
preventable; Insertion site is in the nipple line,
between 4th and 5th ribs!
2. Bleeding; This usually ceases
3. Cardiac puncture. Again preventable, carefully
control the tube going in, DO NOT USE TUBES
WITH TROCARS
4. Passage of tube along chest wall instead of into
chest cavity.In this case, widen and deepen the
dissection between the ribs, and make sure the
insertion of the tube follows this path
 ITEMS FOR EVALUATION OF PERSON
LEARNING THIS PROCEDURE  
1. Anatomy of the chest, lungs, pleura
2. Indications, and contraindications of this
procedure
3. Use of sterile technique and universal
precautions
4. Technical ability
5. Appropriate documentation
6. Understanding of potential complications
and their correction 
 RISKS:
 Risks for any anesthesia are:
 Reactions to medications
 Problems breathing
 Risks for any surgery are:
 Bleeding
 Infection

Outlook (Prognosis)
 Most people completely recover from the

chest tube insertion and removal. There is

only a small scar.
 RECOVERY
 You will stay in the hospital until the
chest tube is removed.
 While the chest tube is in place, the
nursing staff will carefully check for
possible air leaks, breathing difficulties,
and the need for additional oxygen.
 You'll need to breathe deeply and cough
often to help re-expand the lung, assist
with drainage, and prevent fluids from
collecting in the lungs.
Casting and Debridement
WHAT IS A CAST?
 A cast holds a broken bone in place as
it heals.
 Casts also help to prevent or decrease
muscle contractions, and are effective
at providing immobilization, especially
after surgery.
 Casts immobilize the joint above and
the joint below the area that is to be
kept straight and without motion.
 For example, a child with a forearm
fracture will have a long arm cast to
immobilize the wrist and elbow joints.
WHAT ARE CASTS MADE OF?
 The outside, or hard part of the cast, is made from two

different kinds of casting materials.

 plaster - white in color.
 fiberglass - comes in a variety of colors, patterns, and
designs.
 Cotton and other synthetic materials are used to line the

inside of the cast to make it soft and to provide padding

around bony areas, such as the wrist or elbow.
 Special waterproof cast liners may be used under a

fiberglass cast, allowing the child to get the cast wet.

 Consult your child's physician for special cast care

instructions for this type of cast.

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

casts, the location of the body they are applied,

and their general function.
Short arm cast:
 Applied below the elbow to the hand.

 Forearm or wrist fractures. Also used to hold the

forearm or wrist muscles and tendons in place

after surgery.
Long arm cast:
 Applied from the upper arm to the hand.

 Upper arm, elbow, or forearm fractures. Also used to

hold the arm or elbow muscles and tendons in place

after surgery.

Arm cylinder cast:

Applied from the upper arm to
the wrist.
To hold the elbow muscles and
tendons in place after a
dislocation or surgery.
Shoulder spica cast:
 Applied around the trunk of the body to the shoulder,
arm, and hand.
 Shoulder dislocations or after surgery on the shoulder
area.

Minerva cast:
Applied around the neck and
trunk of the body.
After surgery on the neck or
upper back area.
Short leg cast:
 Applied to the area below the knee to the foot.

 Lower leg fractures, severe ankle sprains/strains, or

fractures. Also used to hold the leg or foot muscles

and tendons in place after surgery to allow healing.

Leg cylinder cast:

Applied from the upper thigh to
the ankle.
Knee, or lower leg fractures, knee
dislocations, or after surgery on
the leg or knee area.
Unilateral hip spica cast:
 Applied from the chest to the foot on one leg.

 Thigh fractures. Also used to hold the hip or

thigh muscles and tendons in place after

surgery to allow healing.

One and one-half hip spica

cast:
Applied from the chest to the
foot on one leg to the knee of
the other leg. A bar is placed
between both legs to keep the
hips and legs immobilized.
Thigh fracture. Also used to
Bilateral long leg hip spica cast:
 Applied from the chest to the feet. A bar is placed between
both legs to keep the hips and legs immobilized.
 Pelvis, hip, or thigh fractures. Also used to hold the hip or
thigh muscles and tendons in place after surgery to allow
healing.
Short leg hip spica cast:
 Applied from the chest to the thighs or knees.

 To hold the hip muscles and tendons in place after

surgery to allow healing.

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

bar is placed between both legs to keep the

hips and legs immobilized.
 To hold the hip muscles and tendons in

place after surgery to allow healing.

 How can my child move around while in
a cast?
 Assistive devices for children with casts

include:
 crutches

 walkers

 wagons

 wheelchairs

 reclining wheelchairs
Cast care instructions:
 Keep the cast clean and dry.

 Check for cracks or breaks in the cast.

 Rough edges can be padded to protect the skin

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

inserting objects inside the cast.

 Can use a hairdryer placed on a cool setting to

blow air under the cast and cool down the hot,
itchy skin. Never blow warm or hot air into the
cast.
 Do not put powders or lotion inside the cast.
 Cover the cast while your child is eating to prevent food
spills and crumbs from entering the cast.
 Prevent small toys or objects from being put inside the
cast.
 Elevate the cast above the level of the heart to
decrease swelling.
 Encourage your child to move his/her fingers or toes to
promote circulation.
 Do not use the abduction bar on the cast to lift or carry
the child.
 Older children with body casts may need to use a
bedpan or urinal in order to go to the bathroom.
 Tips to keep body casts clean and dry and prevent skin
irritation around the genital area include the following:
 Use a diaper or sanitary napkin around the genital
area to prevent leakage or splashing of urine.
 Place toilet paper inside the bedpan to prevent urine
from splashing onto the cast or bed.
 Keep the genital area as clean and dry as possible to
prevent skin irritation.
When to call your child's physician:
 Contact your child's physician or

healthcare provider if your child develops

one or more of the following symptoms:
 fever greater than 101° F

 increased pain

 increased swelling above or below the cast

 complaints of numbness or tingling

 drainage or foul odor from the cast

 cool or cold fingers or toes

Debridement
 is the medical removal of a patient's
dead, damaged, or infected tissue
to improve the healing potential of
the remaining healthytissue.
Removal may be surgical,
mechanical, chemical, autolytic(self-
digestion), and by maggot therapy,
where certain species of live
maggots selectively eat only
necrotic tissue.
 Autolytic Debridement:
Description:
 Autolysis uses the body's own enzymes and moisture to

re-hydrate, soften and finally liquefy hard eschar and

slough.
 Autolytic debridement is selective; only necrotic tissue

is liquefied. It is also virtually painless for the patient.

• Autolyticdebridement can be
achieved with the use of
occlusive or semi-occlusive
dressings which maintain wound
fluid in contact with the necrotic
tissue.
• Autolytic debridement can be
achieved with hydrocolloids,
 Best Uses:
 In stage III or IV wounds with light to moderate exudate

Advantages:
Very selective, with no damage to
surrounding skin.
The process is safe, using the body's own
defense mechanisms to clean the wound
of necrotic debris.
Effective, versatile and easy to perform
Little to no pain for the patient
Disadvantages:
Not as rapid as surgical debridement
Wound must be monitored closely for
signs of infection
May promote anaerobic growth if an
occlusive hydrocolloid is used
 Enzymatic Debridement:
Description:
 Chemical enzymes are fast acting products

that produce slough of necrotic tissue. Some

enzymatic debriders are selective, while
some are not.

Best
Uses:
On any
wound
with a
large
amount of
necrotic
 Advantages:
 Fast acting

 Minimal or no damage to healthy

tissue with proper application.

Disadvantages:
Expensive
Requires a prescription
Application must be
performed carefully only
to the necrotic tissue.
May require a specific
secondary dressing
Inflammation or
 Mechanical Debridement:
Description:
 This technique has been used for decades in wound

care. Allowing a dressing to proceed from moist to

wet, then manually removing the dressing causes a
form of non-selective debridement.
 Hydrotherapy is also a type of mechanical

debridement. It's benefits vs. risks are of issue.

Best Uses:
Wounds with
moderate
amounts of
necrotic debris
 Advantages:
Cost of the actual material (ie.
gauze) is low
Disadvantages:
 Non-selective and may traumatize healthy

or healing tissue
 Time consuming

 Can be painful to patient

 Hydrotherapy can cause tissue

maceration. Also, waterborne pathogens

may cause contamination or infection.
Disinfecting additives may be cytotoxic.
 Surgical Debridement:
Description:
 Sharp surgical debridement and laser debridement under
anesthesia are the fastest methods of debridement.
 They are very selective, meaning that the person performing
the debridement has complete control over which tissue is
removed and which is left behind
 Surgical debridement can be performed in the operating room
or at bedside, depending on the extent of the necrotic material.

Best Uses:
Wounds with a
large amount
of necrotic
tissue.
In conjunction
with infected
Advantages:
 Fast and Selective

 Can be extremely effective

Disadvantages:
•Painful to patient
•Costly, especially if an operating
room is required
•Requires transport of patient if
operating room is required.
 Maggots Debridement
 Maggot therapy (also known as maggot
debridement therapy (MDT), larval therapy, larva
therapy, larvae therapy, biodebridement or
biosurgery) is a type of biotherapy involving the
intentional introduction by a health care
practitioner of live, disinfected maggots(fly
larvae) raised in special facilities into the non-
healing skin and soft tissue wound(s) of a human
or animal for the purposes of selectively cleaning
out only the necrotic tissue within a wound
(debridement), disinfection, and promotion of
wound healing.