OBJECTIVES General Objectives: At the end of the case presentation, the students will be able to acquire knowledge, basic skills and develop desirable attitudes through the utilization of the nursing process in the care of patient with lacerated wound. Specific Objectives: Specifically this case presentation aims to: Define lacerated wound. Discuss the Anatomy and Physiology of muscular system specifically the forearm. Identify the causes, signs and risk factors in lacerated wound. Assess client. Identify nursing problems related to lacerated wound. 1
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OBJECTIVES
General Objectives:
At the end of the case presentation, the students will be able to acquire knowledge,
basic skills and develop desirable attitudes through the utilization of the nursing process in
the care of patient with lacerated wound.
Specific Objectives:
Specifically this case presentation aims to:
Define lacerated wound.
Discuss the Anatomy and Physiology of muscular system specifically the
forearm.
Identify the causes, signs and risk factors in lacerated wound.
Assess client.
Identify nursing problems related to lacerated wound.
Plan and implement appropriate nursing interventions for client.
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INTRODUCTION
A wound occurs when the integrity of any tissue is compromised (e.g. skin
breaks, muscle tears, burns, or bone fractures). A wound may be caused by an act, such as a
gunshot, fall, surgical procedure; by an infectious disease; or by an underlying condition; and
in this case, by blast incident.
Lacerations from blunt impacts may show bridging, as connective tissue or
blood vessels are flattened against the underlying hard surface. The term laceration is
commonly misused in reference to incisions.
These wounds are torn, rather than cut. They have ragged, irregular edges and
masses of torn tissue underneath. These wounds are usually made by blunt (as opposed to
sharp) objects. A wound made by a dull knife, for instance, is more likely to be a laceration
than an incision.
Soft tissue injuries of the hand rarely are life threatening. However, the high
incidence of disability from chronically painful or unstable joints is reflected by the fact that
hand derangements account for 9% of all worker compensation claims.
Bomb fragments often cause lacerations. Many of the wounds caused by
accidents with machinery are lacerations; they are often complicated by crushing of tissues as
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well. Lacerations are frequently contaminated with dirt, grease, or other material that is
ground into the tissue. They are therefore very likely to become infected.
The costs for treating these injuries are considerable and include not only the direct
costs of repair but also the indirect costs borne by the patient, his or her family, and society.
These indirect costs include, for example, time off from work and costs incurred while
seeking care.
Skin wounds of the hand, although commonplace, should not be trivialized. They
must be handled with a methodical and thorough approach to optimize outcome and
minimize morbidity.
Antibiotic prophylaxis is indicated in human (including fight-bites) and cat bites and
may be of benefit in dog bites as well. The use of antibiotics in other hand wounds is
controversial but generally is best reserved for contaminated wounds and puncture wounds
with possible retained foreign bodies.
Hand wounds older than 6-8 hours should not be closed primarily because of an
increased likelihood of infections. Irrigate and explore such wounds and apply a sterile
dressing. Recheck the wound in 2-4 days, with consideration of delayed primary closure at 4
days.
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Definition of Terms
Actin – a contractile protein of muscle.
Adenosine Triphosphate (ATP) – a compound that is the important intracellular energy
source; cellular energy.
Creatinine Kinase – an enzyme of the transferase class in muscle, brain and other tissues. It
catalyzes the transfer of a phosphate group from adenosine triphosphate to creatinine,
producing adenosine diphosphate and phosphocreatinine.
Creatinine Phosphate – an enzyme that increases in the blood levels when muscle damage
has occurred, as in pseudohypertrophic muscular dystrophy.
Endomysium – the thin connective tissue surrounding each muscle cell.
Epimysium – the sheath of the fibrous connective tissue surrounding a muscle.
Glycolysis – breakdown of glucose to pyruvic acid; anaerobic process.
Lactic acid – the product of anaerobic metabolism, especially in muscle.
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Muscle – a kind of tissue composed of fibers that are able to contract, causing and allowing
movements of the parts and organs of the body.
Muscular system – all of the muscle of the body, including smooth, cardiac and skeletal or
striated muscle, considered as and interrelated group.
Perimysium – the connective tissue enveloping bundles of muscle fibers.
Pyruvate kinase – is an enzyme involved in glycolysis. It catalyzes the transfer of a
phosphate group from phosphoenolpyruvate (PEP) to ADP, yielding one molecule of
pyruvate
Radius – one of the bones of the forearm lying parallel to the ulna, proximal end is small and
forms a part of the elbow joint, distal end is large and forms a part of the wrist joint.
Sarcomere – the smallest contractile unit of muscle; extends from
Skeletal muscle – are composed of bundle of parallel, striated fibers under voluntary
control.
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ANATOMY AND PHYSIOLOGY
Muscles are often viewed as the "machines" of the body. They help move food from
one organ to another, and carry out our physical movement. There are approximately 639
skeletal muscles in the human body. However, the exact number is difficult to define because
different sources group muscles differently.
Muscle (from Latin musculus, diminutive of mus "mouse") is contractile tissue of the
body and is derived from the mesodermal layer of embryonic germ cells.
One of the most amazing things about the human body is the incredible range of
movement and mobility it has. This day to day activity is accomplished by our muscles
through the extraordinary and fascinating ability of converting chemical energy, energy
stored in nutrients, into mechanical energy, energy of movement.
Within the voluntary skeletal muscles, the glucose molecule can be metabolized
anaerobically in a process called glycolysis which produces two ATP and two lactic acid
molecules in the process (note that in aerobic conditions, lactate is not formed; instead
pyruvate is formed and transmitted through the citric acid cycle).
Biceps brachii – two-headed muscle of anterior arm, proximal to radius, it flexes
elbow and supinates forearm.
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Brachialis – immediately deep to the biceps brachii. Anterior surface of distal
humerus, a major arm flexor.
Brachioradialis – superficial muscle of lateral forearm distal to humerus, synergist of
brachialis in forearm flexion.
Pronator teres – anterior forearm; superficial to brachialis, distal humerus and
choronoid process of ulna it pronates forearm.
Flexor Carpi Radialis – superficial that runs diagonally across forearm, is the medial
epicondyle of humerus, it is the powerful wrist flexor abducts hands.
Flexor Carpi Ulanaris – superficial medial to flexor carpi medialis. The distal to
humerus and posterior to ulna. Powerful flexor of wrist and adduction.
Flexor Digiturom Superficialis – deeper muscle that overlain to all muscle of
forearm, it flexes wrist and middle phalanges of second through fifth fingers.
PHYSIOLOGY
The three (skeletal, cardiac and smooth) types of muscle have significant differences.
However, all three use the movement of actin against myosin to create contraction. In
skeletal muscle, contraction is stimulated by electrical impulses transmitted by the nerves, the
motor nerves and motoneurons in particular.
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All skeletal muscle and many smooth muscle contractions are facilitated by the
neurotransmitter acetylcholine.
Muscular activity accounts for much of the body's energy consumption. All muscle
cells produce adenosine triphosphate (ATP) molecules which are used to power the
movement of the myosin heads. Muscles conserve energy in the form of creatine phosphate
which is generated from ATP and can regenerate ATP when needed with creatine kinase.
Muscles also keep a storage form of glucose in the form of glycogen. Glycogen can
be rapidly converted to glucose when energy is required for sustained, powerful contractions
Muscle cells also contain globules of fat, which are used for energy during aerobic
exercise. The aerobic energy systems take longer to produce the ATP and reach peak
efficiency, and requires many more biochemical steps, but produces significantly more ATP
than anaerobic glycolysis.
A majority of the muscle in the forearm help control a part of the arm. Among these
is the Berachiodialis major-sound, palmaris longus-sound, and Flexor carpi radialis-sound.
The name of the flexor carpi radialis is a good example of how muscles are named by their
function and location. This muscle is named carpi because of the bones that it helps move,
the carples. Also, the name of radialis is made by the bone that its attached to, the radius.
Biographical Data
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Name: Mrs. W. N.
Case Number: 161312-2008
Age: 30 years old
Address: Manika, Libacao, Aklan
Birthday: November 22, 1977
Birthplace: Libacao, AklanSex: Female
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Occupation: Housewife
Blood Type: “O”
Admission Date: September 14, 2008
Admission Time: 2:37PM
Admission Diagnosis: 8cm Laceration in Right Arm ; Nerve Injury 2o to Blast Injury
Attending Physician: Dr. R..J.L.
Chief Complaint: Blast Injury
Principal Operation: “E” Debridement, Exploration of Wound; Myorrhapy possible
Neurorrhapy of Radial Nerve.
Operation Performed: Debridement Myorrhapy Right Forearm with Short Arm Posterior
Mold.
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Vital Signs: BP-145/85 mmHg
PR-100 bpm
SO2- 99%
Hand Dominance: Right Hand
Occupation /Hobbies: Housewife, but occasionally sell goods at her makeshift stall during
market day at their place .
History of previous hand problems: None. Except for minor scratches and lacerations
from ADL’s.
Other past medical history: No history of DM, or other vascular disease.
Lifestyle: Doesn’t smoke, but drinks alcohol occasionally.
History of Current Diagnosis
Prior to admission, at about 9AM , the patient was the attendant of their store.
She placed bottles of beer inside the ice bucket which has been exposed under the sun. At
around 11AM, somebody bought and upon getting the bottle from the bucket, it bursts and its
fragment strikes on her right arm and buried deep into the muscles.
She applied pressure on the lacerated site with her left hand then she
was brought o the health center. Her wound was cleaned and a dressing was applied. The
physician was not there, so she was advised to seek a physician. They went to the doctor near
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their place. The wound was examined and the dressing was changed. She was referred to the
hospital for further treatment since the doctor has incomplete equipments.
HEAD TO TOE ASSESSMENT
Head and neck: No lesion or parasitic infection. Presence of dandruff
Neurologic System: Pupils are uniform in size & shape. Difficulty moving the middle finger
Extremities and Skin: Presence of lacerated wound of the right forearm, even distribution of
hair in extremities
Respiratory: RR of 16bpm, symmetry in chest wall upon breathing, no wheezing, coughing,
rales and dyspnea noted.
Abdomen and GI: Regular bowel movement, presence of bowel sounds, no discoloration or
tenderness noted.
GU: noted a clear lt. yellow colored urine, LMP Aug. 29, 2008, and has regular menstrual
cycle.
24-HOUR DIETARY RECALL
Breakfast: Rice, Fried Egg and a cup of coffee
Lunch: Rice, Sinigang na Baboy, 1 banana
Dinner: Rice, Fried fish and 2 glass of water
LABORATORY & DIAGNOSTIC TEST
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Hematology Report: September 16, 2008 (3:21PM)
Result Normal Values Significance
Hemoglobin 125g/L 120-160 Normal
Hematocrit 0.37volFr 0.36-0.41 Normal
RBC 4.08x1012/L 4.20-5.40 Indicates possible anemia /
hemorrhage
WBC 9.3x109/L 4.50-11 Normal
Platelet Adequate 150-460 Normal
Segmenters 0.63 0.36-0.66 Normal
Lymphocytes 0.37 0.24-0.44 Normal
NURSING CARE PLAN
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Pre-Operative
Assessment
Subjective:
“Nakoebaan ako operahan” as verbalized by patient.