Skills Necessitated in Treating Patients Registering Minor Injury Units to Emergency Departments - Essay Example

Introduction Injuries to the hand can present a challenge for nurses working within the emergency department. These injuries may not be life-threatening; nevertheless, the intricacy of the area can present multiple challenges during diagnosis and treatment. Inappropriately diagnosed and managed injuries can yield to chronic pain, incapability to undertake activities of daily living, and the seemingly minor injuries can yield to missed work and the resultant cost to society. There is lack of a widespread definition of the term minor injury. Minor injuries should be viewed within the context of nurses’ scope of practice limits placed on nurses’ working within a certain healthcare setting. The term injury refers to describe a mechanical event where a body part may be stressed by a disproportionate force and/or damaged. The aim of this paper centres on enhancing nurses’ knowledge and understanding of the skills necessitated in assessing and treating patients registering minor injury units to emergency departments. The paper explores the clinical assessment process and avails an overview on the management of common minor injuries. The paper reviews the case presented of Anne Rutter (45yrs old) centring on the injuries to the hand and wrist and discusses the diagnostic and treatment plans that the nurses working within the emergency department can utilize to treat the patient effectively and minimize their exposure to risk. Somatic pain that emanates from the skin, muscles, bones, ligaments, and joints can be regarded as the most prevalent form of pain encountered in musculoskeletal injuries. Somatic pain can be categorized into two types: deep and superficial. Usually, deep somatic pain is lasting and mainly indicative of sizable tissue damage to the internal joint structures/muscles (OConnor 2013, p.87). Wrist and sprains have analogous signs and symptoms but differ anatomically. Wrist sprains and sprains mainly result from a fall onto an outstretched hand. The hand’s position and/or rotation at point of impact determine the form of and severity of the injury. Complex wrist and hand anatomy can render a diagnosis of wrist injuries on a challenging task (Parmelee-Peters and Eathorne 2005, p.35). The scaphoid represents the most dominantly injured carpal bone, accounting for close to 70% of carpal fractures. The management of wrist injuries should encompass rehabilitation of muscles weakened and motion lost by pain, immobilization, and inflammation. The rehabilitation should respond to five goal-oriented phases: (1) minimizing pain and inflammation, as well as oedema, if present; (2) enhancing pain-free range of motion; (3) reinforcing and enhancing general condition; (4) enhancing coordination and flexibility; (5) returning to normal work with prevention of injury that may include utilization of protective equipment (Moulton and Yates 2012, p.125). Discussion Scenario 1: The immediate pain in the left wrist below the thumb could arise from sprained thumb injury sustained after the fall. A sprained thumb is a dominant cause of thumb pain and swelling. This may emanate from damage to the Ulnar Collateral Ligament at the base of the thumb. In cases where the patient experiences severe sprained thumb injuries, there is frequent immediate thumb swelling and bruising may develop. The capability to pinch grip small objects maybe frequently impaired owing to the resultant instability within the Meta-Carpo-Phalangeal (MCP joint). Diagnosis for sprained thumb made through physical examination, whereby stressing the Ulnar Collateral Ligament may reveal instability within the joint (Kamper, Mahoney, Nelson, and Peterson 2001, p.371). This can be confirmed by undertaking an x-ray while stressing the joint; nevertheless, x-ray evidence may not be always helpful in isolation. Sprains usually tend to resolve in a period of about 4-6 weeks and can be aided by physiotherapy treatment. Ultrasound can be an effective mode of assessment in the early stages, coupled with mobilization, can help in the ligament repair, and aid in the restoration of function. In cases where there is total rupture of the Ulnar Collateral Ligament, surgical repair may be undertaken (Mirabelli, 2013). In some instances, the ruptured ligament may become entangled within the soft tissue at the base of the thumb. Scenario 2: Given that the pain that the patient is experiencing localized pain, this implies that Anne Rutter has sustained limited ligament damage. Sharp, stabbing pain felt during activity may be indicative of severe injury such as ligament sprain or muscular strain. There are a number of mechanisms of injury for a sprained wrist including twisting of the wrist, falling on an outstretched arm, and hyperextension or hyper-flexion of the wrist/hand (Kulkarni 2008, p.2456). A fall onto, an outstretched hand, can yield to a scaphoid fracture, which is the most dominant fractured carpal bone. Conventional radiography may miss up close to 30% of the scaphoid fractures. A dominant clinical presentation is resultant of sudden onset wrist pain characteristically as a result of a fall onto an outstretched hand caused by ligaments or connective tissue around the wrist such as sprained wrist, or intermittently a fracture such as a radius fracture, or scaphoid fracture. A sprained wrist is fairly dominant injury resultant from a fall on an outstretched hand (Navarro, Ponzer, Tornkvist, Ahrengart, and Bergstrom 2011, p.171). The wrist comprises of eight small carpal bones connected to metacarpal bones on one side, plus forearm bones (radius and Ulna) on the other side (Purcell and Cooper 2010, p.4). Differential Diagnoses History: The nurse should relate a history of injury such as falling and the patients complains of pain, as well as other characteristics that may be visible. The diagnosis of a wrist injury can be complicated given that there are multiple ligaments stabilizing the wrist. Some ligaments stabilize the radius and Ulna to their adjoining carpal bones, as well as ligaments that stabilize individual carpal bone to its adjoining carpal bone, plus the ligaments stabilize the distal carpal bones to the metacarpal bones. The hand and wrist anatomy and physiology detail complex structures with extensive tendons, muscles, ligaments, and vascular and nerve supplies. Given that a significant number of ligaments situated within a wrist, it is possible for a patient to sustain injuries to multiple ligaments in the event of a significant injury. Physical examination: The physician may highlight localized swelling of the wrist and pain on a range of motion. The nurse should formulate a diagnosis, treatment and appropriate referral plan for patients presenting with a minor injury (Robinson 2010, p.152). The clinical evaluation highlights several critical areas such as location of pain, mechanism of injury, associated sounds, and history of injury. The critical areas to observe encompass: the surrounding environment, body position, movement of the individual, degree of responsiveness, and primary survey (Cooney 2010, p.431). The musculoskeletal assessment should be a straightforward as possible and the nurse could employ “look, feel, move” approach. This is pertinent to clinical decision making to enable the clinicians reach conclusions on probable diagnoses. In making the assessment, the nurse should examine the injury site for bruising, deformity, and swelling (look). Similarly, the nurse should investigate the injured area to restrain other injury prior to palpating the bones close to the injury site. Where the mechanism on injury indicates probable scaphoid fracture, the nurse should carry out scaphoid tests detailed in the tests (feel). The nurse should also request the patient to make a wide range of hand and wrist movements including extension, flexion, Ulna, and radial deviation (Chaitow, Delany and Chaitow 2005, p.80). Sprained Wrist Tearing of ligaments and/or connective tissue of the wrist joint characteristically result from a fall onto an outstretched hand, which makes the wrist stretch excessively. Sprained wrist can be linked to pain in the wrist, and limited joint mobility, and restricted wrist. Radius Fracture Radius fracture result from a break in the radius bone close to the wrist mainly due to a fall onto an outstretched hand, and is linked to severe pain that may radiate into the thumb, forearm, or hand, and markedly minimized wrist function. Scaphoid Fracture In most instances, the breakage of a bone is obvious to the patient as the area the painful may be painful, deformed, or swollen. However, this is not always the case as a bone can break without of one realizing it, which often occurs in cases of the scaphoid bone. The scaphoid is the most recurrent site of carpal fracture and intercarpal ligament injury (Watanabe, Souza, Vezeridis, Blazar, and Yoshioka 2010, p.837). Radiographically, the scaphoid is identifiable structures entail distal pole, the proximal pole, and the volar tubercle situated at the distal pole. All of the outlined structures can be identified on conventional radiographs derived from planes other than only the PA or lateral (Hersen 2004, p.129). Majority of patients with fractured scaphoid perceives that they have a sprained wrist rather than a broken bone, given that there is no apparent deformity and very minimal swelling. A scaphoid fracture represents a break within one of the wrist bones situated on the thumb side of the wrist mainly owing to a fall onto am outstretched hand. Scaphoid fracture can be linked to severe pain at the moment of injury that may settle to an ache, mainly situated on the thumb side of the wrist (Jones, Endacott, and Crouch 2003, p.135). The mechanism of injury is most prevalent owing to hyperextension of the wrist; although, it can also be a consequence of a pure compressive force. A fall on an outstretched hand may yield to Palmar tensile and dorsal compressive force on the scaphoid (Tornetta and Wiesel 2010, p.511). Scaphoid fractures account for close to 60% of all wrist (carpal) fractures in which the break mainly manifests in a fall on the outstretched wrist, in which the angle of the fall is a significant determinant of the injury sustained, whereby if the wrist is bent at a 90° angle or greater, the scaphoid bone, is likely to break, and if the angle is 1 mm of the displacement established between the fragments, or in the event that the fragments are angled (Slutsky and Osterman 2009, p.219). Moreover, the fracture can be regarded as unstable in the event that the lateral radiographic view indicates misalignment of the carpal bones, which is indicative of fracture dislocation. The healing time for the injury varies and can range from 6 weeks (for the fractures established within the top portion) to 6 months (for fractures located within the lower portion). The cast ought to be regularly checked to guarantee that it fits properly and safeguards against movement. Subsequent to the removal of the cast, rehabilitation program may aid to reinstate a range of strength and motion. However, even with instant cast immobilization, not all scaphoid fractures will heal properly. Surgery may be necessitated in cases of a fracture displacement or in cases where there are other injuries (Goldfarb et al. 2001, p.11). Further test & investigations Musculoskeletal Ultrasound of the hand and wrist has continuously been employed in clinical practice. The rapid advances registered in this field such as new ultra-high frequency probes have yielded to enhanced image quality and quickened the growth of musculoskeletal ultrasound (Fleisher 2002, p.589). Ultrasound enables the detection of foreign bodies, and aids in reliable identification of diverse traumatic lesions impacting on tendons, ligaments, vessels, and nerves. Differential diagnosis of a suspected scaphoid injury may entail sustained fractures on metacarpal bones, arthritis, tenosynovitis, or strains. There are a number of imaging options that the clinician can employ in assessing the patient with a suspected injury including magnetic resonance imaging, ultrasonography, bone scintigraphy, and plain radiographs (Guertler 1997, p.303). All of the outlined modalities present distinct advantages and disadvantages, which is pertinent in evaluating patients for possible scaphoid fracture. Radiographic assessment of a suspected scaphoid injury entails the acquisition of PA, lateral “scaphoid” views (detailing PA radiograph spotlighting the scaphoid in which the wrist is held in ulnar deviation) and external oblique. The radiographic views should highlight the bulk of scaphoid fractures. Unless, the fracture is displaced, the initial diagnosing of a scaphoid fracture can be difficult; this necessitates a series of X-rays for confirmation. Routine radiographs of the scaphoid may entail anteroposterior (AP), oblique, and lateral based on the horizontal views (Oetgen and Dodds 2008, p.97). An AP view with tightly clenched fist and ulnar deviation can be employed to establish ligament injury. Disruption of the alignment may be indicative of ligament injury or dislocation, angulations, or displacement of a fracture. Referral / follow up plan Follow up plans mainly result from a fall, and, as such, the patient should be careful to avoid a re-occurrence of the injury. Wrist guard splints or protective tape can be employed to support the wrist and safeguard against bending too far backward (Obi 2004, p.82). Physiotherapy for a scaphoid fracture may entail joint mobilization, soft tissue massage, taping or bracing, ice heat treatment, utilization of compression damage, and dry needling. Some of the exercises for a scaphoid fracture prescribed to patients with a fractured scaphoid following healing entail elbow bend, wrist bend, and forearm rotations (Gloster and Ganley 2012, p.50). Conclusion Hand injury is a dominant presentation within primary care and the accident and emergency department. Assessment is a critical component of the nurses’ role and responsibility while availing safe and component case to the assigned patients. Emergency department triage necessitates that nurses exercise sound clinical judgments based on their professional experience and training. 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