Nursing and Medical Science in Orthopaedics - Essay Example

Nursing and Medical Science in Orthopaedics Skeletal Pin Site Management Accidents happen when a personleast expected it. These accidents may often result to wounds, injuries and fractured bones. While a patient is being confined in the hospital, a nurse plays a vital role in taking care of the patient and attending to its proper medication. Nurses also contribute a lot in pain management and infection management. As the saying goes, "prevention is better than cure", skeletal pin site management is being developed to take care as well as prevent infections of patients with external fixators. External fixation is described as a surgical routine that drills holes into the uninjured areas of bones around the fracture and screw special bolts into the holes. This is done to set bone fractures in which a cast would not allow proper alignment of the fracture. A rod with special ball-and-socket joints joins the bolts to make a rigid support, is placed outside the body. By adjusting the ball-and-socket joints, the fracture can be set in the proper anatomical configuration. Compared to other types of cast used in fractured bones external fixation is used most frequently. This is because the patient will be able to mobilize earlier than other types of fixations which means, the patient will have to spend shorter time in the hospital. It was also observed that external fixations enables the patient to cope up early and perform almost all its normal activities. On the other hand, pin sites are locations on which pins are inserted into the hole created in the unfractured and soft bone. It serves as an entry and exit in the skin to provide skeletal traction or external fixation apparatus. Installation of external fixations, more often than not, developed pin site infections. Signs of reaction include changes in normal skin color, increased warmth, and serous or slightly bloody drainage at the pin site. Importantly, a pin site reaction is not a pin site infection. (Holmes and Brown, 2005) The swelling is a common reaction of the body's tissue in the presence of foreign bodies such as pins. This will develop to pin site infection if not managed properly. With this, pin site management is practised by regularly checking the areas where the external fixators were attached and checking it for signs of infection such as tenting, redness, tenderness and purulent drainage. This also involves regular cleaning of the pin sites. However, different medical establishments apply different ways of cleaning; different procedures in cleansing, varied frequency and techniques for applying cleansing agent(s), removal of crusts, and use of dressings. In this research, procedures of skeletal pin site management are being studied to be able to evaluate and recommend the best and effective way in managing external fixations and pin tract infection. The goals are to keep swelling and pain caused by surgery to a low level, provide exercises to increase circulation and start wound (pin) care to prevent infection. Current Procedure Royal Darwin Hospital's procedures in managing pin sites are as follows: Put a betadine gauze around the pin sites for 48hours. After 48 hours, removed the betadine gauze and leave the pins sites alone. These will not be cleaned to leave the crusts intact. If the pin sites become infected, they are cleaned through the direction of the consultant. This practise however, is in contrast of what Lisa Marie Bernardo has said in her article, Evidence-based Practice for Pin Site Care in Injured Children which says "there is a general agreement that pin sites of patients receiving external fixation should be inspected and cleansed to prevent infection. (Bernardo, October 2001) The fact that the pin sites were not cleaned after 48 hours to leave the crust intact will have a possibility of greater risk of infection. On the other hand, cleaning through the direction of a consultant will leave the nurses dependent to the consultant and cannot act as freely as or independently even though they already felt that cleaning should be needed. Although, there is still no agreement to the standards of practise for pin care management, regular monitoring is needed to prevent infection and protect the patient for further damage or osteomyelitis (bone infection). This standardization of procedure will also help orthopaedic nurses in developing a sense of ownership wherein, a direction of the consultant will not be needed every cleaning schedule of pin sites, unless the condition of the patient and pin site infection is very critical. Current Literature Infection rates for external fixation are climbing high and it is now evident that steps for skeletal pin site management should be taken to avoid the risk of infection. It was suggested that increased intervention to the pin site was associated with an increase in pin-site reaction or infection. (Trigueiro, 1983). Paley and Jackson (1985) acknowledged this statement by raising the question of whether there should be any active intervention, such as cleaning or dressing, at the pin site at all. After Triguero had conducted her survey, application of a Kling type dressing in the first 24 hours is suggested to control oozing and keep the wounds clean. Aside from that, Kling type dressing avoids further tearing of the skin. After 24 hours, the dressing will be removed and an anti microbial should be used to clean the sites. Using of Hydrogine Peroxide is discouraged for it is discovered to damage healthy tissues. In a study conducted by Keneth Egol, MD (February 2006) and his colleagues, the group which receives a daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide, more patients developed erytherna, cellulitis and drainage compare to those who were treated with a weekly dry dressing and placement of a Biopatch dressing over the pin sites, with the dressing being held in place with a sterile gauze wrap. For pin loosening and radiographic loosening, only those who were treated with hydrogen peroxide developed this kind of infection. The crusts act as a protection that's why she recommends that crusts should not be removed so that the risk of infection should not increase. The crusts should only be removed when continuous drainage is present. The tightness or looseness of the pins should be checked daily. If excessive skin pressure from the pins was found, it should be reported immediately to the surgeon. The looseness of the pins may risk the bone by becoming unstable. It is also important that the cleaning of draining sites should be included in the nurse's daily task, and should be covered with dry dressings. Signs and symptoms of infection, such as foul odour, pain, redness, tenderness, and low grade temperature should be observed daily. Purulent discharge should be cultured. There are also some common cleansing methods applied to pin sites such as cleaning pin sites with tap or soap water, one to four times daily; Spraying each pin site with normal saline, using sterile syringes; Cleansing with 100% peroxide alone or in conjunction with a Betadine ointment; Pouring sodium chloride over the pin site four times daily; Applying antibacterial ointment or antiseptic ointment only; Changing dressings one or two times daily without specific cleaning of the pin site; Cleaning pin sites one to four times daily with Hibiclens or Betadine solution and covering with sponges or dressings; and Showering. These practices however is associated with problems such as cross-contamination of the pin sites, sealing in of infectious process by ointments, allergies to the cleaning agents, skin irritations caused by the cleaning agents and the requirement for numerous clinic visits. Current Procedure vs. Literature These different procedures show that there are hospitals practising a lenient skeletal pin site management and there are those who practise stricter preventive measures. Infections also occur due to malpractice and negligence of an out patient due to lack of knowledge in caring for the pin sites. In these examples, there are identified strengths and weaknesses of each practise. Compare to the practise of Royal Darwin Hospital, a Kling type dressing protects the wounds better than that of putting betadine gauze around the pin sites. Betadine Gauze is anti-microbial and prevents infection but having it uncleaned for 48 hours or 2 days will diminish the effectivity of the Betadine. On the other hand, Kling type dressing acts as a support and protection of the wounds to prevent it from further tearing and keeping it clean. The fact that the sites are cleaned and applied with anti-microbial every 24 hours is more hygienic compared to leaving it wrapped and uncleaned every 48 hours. If this is the case, there is a greater risk of infection than checking and cleaning it every 24 hours. Leaving the crust intact is commonly practised for the two samples. This is for the reason that the crust further protects the wound from getting infected. It acted as a natural seal so infection is less likely to get in. Leaving it uncleaned still allows microbes and bacteria to accumulate on the pin sites and develop an infection. Compared to the current literature, the development and condition of pin sites are checked daily unlike the current procedures that pin sites were left alone after removing the betadine gauze allowing it to be more exposed and vulnerable to infection due to the absence of microbial protection. The daily task of checking for pressure, cleaning and draining the sites as well as replacing of dry clean bandage which is practised in the current literature is more comprehensive in preventing infection rather than waiting for it to get infected before calling a consultant or a surgeon or before they are even cleaned. In every case of external fixations, most of them got infected therefore it is important to have a proper hygiene and correct practises in dealing with it to prevent further pain and infection. Recommendation Slight pin site infection is characterized by slight discharge, redness of the skin and soft tissue tenderness. When severe cases of pin site infections occur, antibiotics are no longer effective, there is a foul odour and severe soft tissue which involves more than one pin and sometimes accompanied by osteomyelitis and sepuestrum forms within the bone. These required surgery therefore, to prevent severe infections, skeletal pin site management should be developed. The major recommendations in the developing of pin site management procedures are ideally focused on practices that will eliminate or reduce the severity of infection and better yet, prevent its occurrence. It is very important that the wound should be protected and the external fixators are solidly attached. Movements of the external fixator will stretch the wound thus making it bigger. The type and placement of the pin, including its coating, affect its stability and the correction of pin placement increases its risk to infection. In order to protect pin site and to keep it stable, Kling type dressing should be applied in the first 48-72 hours to avoid further tearing of the wound after which, it should be removed but leave the pin sites uncleaned. This would leave the pin sites untouched and allows the wound to heal faster. According to Paley and Jackson (1985), the skin movements around the pins also increase the risk of an infection. Through Kling typre dressing, pin complications such as erytherna, cellulites and pin loosening will be reduced. In a study being conducted, the control group, where no cleaning was implemented, showed the lowest infection rate (7.5% of pin sites (n = 3)). This group also showed less crust formation. (Williams & Griffiths, 2004) According to Mikki Patterson (2005), stable dressing specified no pin cleansing with stable gauze/sponges and required changing only if the dressing became wet or soiled. Remove the crusts. This is to promote free drainage and to prevent the skin from adhering to the pin, thus allowing exudate to collect, leading to inflammation and infection. (Santy, 2000) Due to the absence of pin site cleaning, these sites will be sprayed daily with an anti-microbial agent or povidone iodine. After which, these sites will be wrapped with a clean, dry sterile gauze or dressing. One study showed that a regime of crust removal and spraying with povidone iodine was associated with fewer infections than regimes involving cleaning with alcohol or normal saline. (Williams & Griffiths, 2004) There are also some techniques used for admitted patients and out patients. Sterile technique (sterile material and sterile gloves) was used in the hospital and clean technique (sterile material and clean gloves) was practised in the outpatient clinic and at home by the district nurses. All bandages were removed. Each pin site was cleaned with a 0.9% NaCl solution. A cotton-pin was used to take away the crusts. Put a sterile compress on to each pin-pair and fixed with a soft dry dressing. Massage the skin near the pin sites to enhance its flexibility. It also helps in preventing the skin to stick to the pin. In taking care of the dressing, the pin sites should be covered with plastic in order to protect the sites from getting wet. Wetness and moist encourages infection especially when the climate is tropical humid. It is also recommended that before the discharge of the patient from the hospital, the patient or the family should be taught about pin site care for them to develop a sense of ownership, thus, they will be able to attend to their external fixations and proper hygiene so as not to develop serious complications in the pin sites. For them to be able to understand fully on what to do, proper caring for the pin sites should be demonstrated before them. Written instructions which contain a step-by-step procedure on caring for the pin sites, illustrations on how to do it and illustrations of infections as well as signs and symptoms of infection should be provided. The patient should fully understand that the due to the existence of external fixations, they will have restrictions in movements and should follow instructions about pin care, wound care, movement and weight-bearing exercises so that they will recover faster. CONCLUSION Proper procedure for skeletal pin site management is important and in nursing for a patient with external fixators, there are six vital fields that need specialized nursing attention. These are the proper dressing and caring for the wound, neurovascular function, mobility, pain management, proper hygiene practices, clothing and psychosocial care. Topical antibiotics, antibacterial pin coatings, and a variety of pin-care techniques do not prevent clinically important pin-track infections. (J.L. Marsh, MD, 2003) These are all critical areas to attend to and applying holistic care is recommended. On the other hand, the presence of the external fixators also has an effect on the lives of the patients. In attending for the proper dressing and caring for the wound, procedures should be well followed considering also the condition of the wound such as the amount of drainage around the pin. Pin sites should be inspected at least daily for signs of looseness of pins, tightness of the skin and of the pins, pain, swelling, discoloration, redness and the colour of its secretion. Neurovascular functions should also be inspected for risk of coetaneous nerve injury due to swelling and muscle impingement. The presence of the pins may disrupt the normal functions of the blood circulation, blood vessels and the nerves surrounding soft tissue and bones. There should be a pattern in regulating and integrating into the daily program of illness treatment to avoid the risk of being invaded with pathogenic agents such as viruses, bacteria, fungus and other parasites to prevent the destruction of the nerves. The thought of having an external fixator and the appearance of the device may most likely cause fear and trauma not only for the family members but most of all, the patient. It will be the nurse's duty to enhance the mobility of the patient for him to be able to move or change. Depending on the patients motor skills, special tools such as a walking stick, walker or wheelchair, vehicles, uncongested roads and public transport may be needed. Exercise programs as well as mobility plans are to be provided. The full understanding of the nurses with regards to the mobility plan is very important so they can carry it out with and to the patient. Infections can cause pain to the patient. There are those infections that cannot be treated with antibiotics and needs surgery. To avoid these infections and to manage the pain, proper hygiene is needed. After being discharged from the hospital, patients are now capable of self care, proper hygiene and careful dressing to ensure that there is no further damage contributed to the pin sites. Proper hygiene also includes bathing, however, the sites were the external fixator is attached should be cover with plastic due to the following reasons; unclean bath water coming from any part of the body will contain dirt, detergents, soap and other contaminants which will irritate the wounds and the pin sites. Warm water will also make the skin soft and sluggish that will also lead to irritation and infections of the pin sites. Pain can also be managed with the use of analgesics. However, one of the basis for the patients mobility is on how he manages the pain that he feels. The better the patient manages the pain and sensations, the better for him to cope up with the compliance of his treatment and medication. Pain management includes regular assessing of patients pain and taking appropriate measures in managing it. This would also include relaxation and reflexology. Up to now, there are still no standard procedures in skeletal pin site management. The above standard is based on the available knowledge and literature and is sufficiently 'evidence based' to provide guidelines for pin-site care until such time when further extensive, generalisable controlled clinical trials have been undertaken. Nurses need to be sensitive in providing physical and psychosocial care to patients and their families. Through these proper procedures, holistic care can be provided and proper training, education and information for nurses, patient and families will provide a sense of ownership which will be needed in order to prevent further complications. A kit for external fixation pin site care in conjunction with practicing a uniform and consistent standardized protocol to significantly reduce post-operative infection risk is provided. The kit contains labeled treatment materials to be used in the newly-designed, standard post-operative cleansing and infection treatment procedure. The result is significantly reduced incidences of infection at the pin/skin interface of patients. (Allen and Pania, 1999) Traumatic as it may seem, the knowledge that the patient is properly taken care of by practising a standardized procedure will ease the pain and burden of both the patient and nurses. Standardization and education for both patient and nurses can make a difference on how they see the external fixation case and skeletal pin site management. REFERENCE Allen, Robert E. and Jody S. Panian.( 9 November 1999) Pin care kit and method. Free Patents Online {online] Available from: http://www.freepatentsonline.com/5979658.html [Accessed 3 June 2006] Bernardo, Lisa Marie (October 2001) Evidence-based Practice for Pin Site Care in Injured Children. Orthopaedic Nursing. Volume 20 Egol, Kenneth A. et. al. (February 2006) Treatment of External Fixation Pins About the Wrist: A Prospective, Randomized Trial. The Journal Of Bone And Joint Surgery, Incorporated. Copyright 2006 Holmes, Sue Baird and Sarah Jo Brown (2005) Skeletal Pin Site Care National Association of Orthopaedic Nurses Guidelines for Orthopaedic Nursing. Orthopaedic Nursing Volume 24 No. 2 Marsh, J.L. MD (December 2003) Weekly Pin-Site Care Was as Effective as Daily Care in Patients with External Fixation. Evidence-Based Orthopaedics. Volume 86-a Number 8 August 2004 Paley D, Jackson RW (1985) Surgical scrub sponges as part of the traction apparatus: an alternative to pin site care to reduce pin track infections. Injury 16(9): 605-6 Patterson, Mikki M. (2005) Multicenter Pin Care Study. Orthopaedic Nursing Volume 24 No. 5 Santy J (21 January 2000) Nursing the patient with an external fixator. Continuing Professional Development: Orthopaedic Nursing. Available from: http://www.nursing-standard.co.uk/archives/ns/vol14-31/pdfs/p4752w31.pdf#search='Skeletal%20Pin%20site%20management%20procedure' [Accessed 2 June 2006] Trigueiro M (1983) Pin site care protocol. Can Nurse 79(8): 24-6 Williams, Heather & Peter Griffiths (2004) The effectiveness of pin site care for patients with external fixators. British Journal of Community Nursing, 2004, Vol 9, No 5 Available from: http://www.kcl.ac.uk/ip/petergriffiths/ebdm/papers/pinsite.pdf [Accessed 1 June 2006] Read More