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NURS 6541 Comprehensive Final Exam Review (Week 1-11)
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cushNURS 6541 Comprehensive Final Exam Review (Week 1-11)You will be tested over weeks 1-11 on this Blackboard Exam
****For weeks 1-6, review Midterm Study Guide****
Week 7: Dermatology disorders
Bug bites and bee stings –
Dog bites, cat bites –
Dog Bite: about the circumstances surrounding the bite including the type of animal, domesticated or
feral animal, provoked or unprovoked attack, and location of the attack. History of drug allergies and
immunization status of the child also should be ascertained.
Physical Examination.
The wound should be assessed for the type, size, and depth of injury. Explore for the presence of foreign
material and the status of underlying structures. If the bite is on an extremity, assess its range of motion and
sensory intactness. Likewise, assess functioning of the facial nerve with deep facial bite injuries. At minimum, a
diagram of the injury should be recorded in the child's chart (Ginsburg, 2011). If possible, it is best to photograph
the injury for documentation.
Diagnostic Studies.
Aerobic and anaerobic cultures should be obtained from wounds exhibiting signs of infection (Buttaravoli and
Leffler, 2012). A radiograph of the affected part should be obtained if it is likely that a bone or joint could have
been penetrated or fractured or if retained foreign material may be present.
Differential Diagnosis
The differential diagnosis includes lacerations or puncture wounds from other causes.
Management
Management involves both physical and psychological care of the child and includes the following (Mandt and
Grubenhoff, 2014):
• Administer tetanus booster and rabies prophylaxis if indicated (consult with local animal control or public
health department).
• Provide/administer appropriate analgesia or anesthesia.
• Débride avulsed or devitalized tissue and remove foreign matter.
• Using normal saline, irrigate the wounds using high pressure (greater than 4 pounds per square inch) and high
volume (greater than 1 L).
• Isolated puncture wounds should not be irrigated, instead soak the wound in a diluted solution of tap
water and povidone-iodine for 15 minutes.
• Prescribe a 3- to 5-day course of prophylactic antibiotics for all human and cat bites, and for the following types
of bite or wound characteristics: hand, puncture, overlying bone fracture, substantial crushing tissue injuries or
if requiring débridement, or those involving tendons, muscles, or joint spaces. In addition, antibiotic coverage is
needed for wounds in children who are immunosuppressed. For outpatients, prescribe a broad-spectrum
, antibiotic, such as amoxicillin clavulanate (first choice). Penicillin-allergic individuals should be treated with an
extended spectrum cephalosporin or trimethoprim-sulfamethoxazole plus clindamycin (Hodge, 2010).
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• Rabies exposure prophylaxis also should be considered if there is any question about possible exposure. The
CDC provides guidelines on prophylaxis for possible rabies (see Additional Resources). The local health
department is also a good resource for guidance on postexposure prophylaxis for rabies.
• Some controversy exists over whether bite wounds should be closed primarily with delayed closure (3 to 5 days
after injury) or allowed to heal by secondary intention (leaving the wound open). Factors to consider are the
type, size, and depth of the wound; the anatomic location; presence of infection; the time interval since the
injury; and the potential for cosmetic disfigurement. Surgical consultation should be obtained for all deep or
extensive wounds and those involving the bones, joints, or hands. Because of the excellent blood supply to
the face, facial lacerations are at less risk for infection. Many plastic surgeons advocate primary closure of facial
bite wounds that have been brought to medical attention within 5 to 6 hours and have been thoroughly
irrigated and débrided. Because of concern about scarring, the provider may refer facial wounds for plastic
surgery repair.
• There is consensus that bites involving the hand or foot should not be sutured but allowed to drain. Hand
and foot bites less than 1.5 cm are best left to heal by secondary intention; bites greater than 1.5 cm
should have delayed primary closure.
• Bite wounds more than 8 to 12 hours old should not be sutured except for facial wounds that can be
sutured up to 24 hours, maximum.
• A single layer of nonabsorbable sutures is best (avoid multiple closure layers).
• Refer children with severe bites. Obtain a surgical consult if there is evidence of or concern about nerve,
tendon, and/or ligament injury or if a joint space was involved. Hospitalization, reconstructive surgery,
and long-term follow-up may be indicated.
• Discuss the child's fears and management of any behavioral problems that may result (see Chapter 19).
• Report dog and wild animal bites to animal control.
Complications
Secondary infection is the most common complication of mammalian bites and can lead to cellulitis and
lymphangitis, requiring hospitalization. Streptococcus and Staphylococcus are common organisms associated
with infected animal and human bites; anaerobic infection is also possible. Species of gram-negative bacteria
(such as, P. multocida from dog and cat bites and Eikenella corrodens from human bites) can also cause infections
(Krennerich, 2015). The potential for rabies, human immunodeficiency virus (HIV), and hepatitis B and C
exposure must also be considered.
Patient and Parent Education
Preventive education and actions should include the following:
• Teach children to avoid stray animals, be cautious around domesticated animals, and not tease or provoke any
animal.
• Emphasize the importance of parental supervision of children as they play with pets.
,• Do not keep typically wild animals as pets in families with very young children.
• Do not allow pets to roam freely.
• Never leave infants or young children alone with dogs or cats; animals with histories of aggression are
inappropriate in households with children.
• Report stray animals promptly to animal control officials.
Cat bite: Cat and dog bites can cause wound infect ion from Pasteurella multocida.
When considering risk for infection, the location and depth of the wound and the presence of a foreign
object are important components. For example, deep penetrating injuries to the forefoot with a dirty
object, especially if they involve the plantar fascia, have a higher risk of infection than wounds to the
arch or heel area. The forefoot has less overlying soft tissue than other plantar surfaces and is the major
weight-bearing area of the foot; therefore, cartilage and bone can be involved. The metatarsophalangeal
joint region is also at high risk for infection for the same reasons. Puncture wounds through the soles of
tennis shoes can transfer bacteria into the tissue while simultaneously impairing wound drainage,
placing the child at higher risk for a secondary infection.
Puncture wounds result from penetration of varying levels of skin and underlying tissue. These wounds
are typically classified as superficial or deep. Glass, wood splinters, toothpicks, needles, nails, metal,
staples, thumbtacks, and bites are common sources of injury. Although the majority of puncture wounds
heal without problems, a sizable minority of these injuries are complicated by infections that can lead to
cellulitis, fasciitis, septic arthritis, or soft-tissue abscesses.
Staphylococcus aureus and beta-hemolytic streptococci are normal flora of the skin and are common
causes of secondary infections in puncture wounds. Pseudomonas aeruginosa colonizes on the rubber
soles of tennis shoes and is a common pathogen for plantar puncture wounds when the puncture occurs
through the sole of a tennis shoe and into the foot. Osteomyelitis can occur if the puncture wound
penetrates a bone or joint and is most commonly caused by P. aeruginosa in nondiabetic patients and is
most commonly caused by S. aureus in diabetic patients (Baddour, 2013). Cat and dog bites can cause
wound infection from Pasteurella multocida.
When considering risk for infection, the location and depth of the wound and the presence of a foreign
object are important components. For example, deep penetrating injuries to the forefoot with a dirty
object, especially if they involve the plantar fascia, have a higher risk of infection than wounds to the
arch or heel area. The forefoot has less overlying soft tissue than other plantar surfaces and is the major
weight-bearing area of the foot; therefore, cartilage and bone can be involved. The metatarsophalangeal
joint region is also at high risk for infection for the same reasons. Puncture wounds through the soles of
tennis shoes can transfer bacteria into the tissue while simultaneously impairing wound drainage,
placing the child at higher risk for a secondary infection.
Assessment
The assessment of a child with a minor wound begins by excluding more serious and sometimes occult
injuries.
History.
Important information to elicit after a report or suspicion of a puncture wound includes the following:
• Date and time of injury and history of wound care provided at time of injury and thereafter.
• Identification of the penetrating object and the type and estimated depth of penetration. If it is not
known what object penetrated the skin, the likelihood of an imbedded foreign body is high.
• Location and condition of the penetrating object. Was the object clean or rusty, jagged or smooth?
• Whether all or part of the foreign object was removed.
• Type and condition of footwear that was being worn (pertinent to injuries to the foot) or if the child
was barefoot.
, • Immunization status for tetanus coverage (see Chapter 24).
• Presence of any medical condition that increases the risk for infectious complications.
Physical Examination.
A good light source is necessary to assess and treat a puncture wound. Note circulation, movement, and
sensation of the area next to the injury. Determine the amount of involvement of underlying tissue or
bone structures. For plantar puncture wounds, have the patient lie prone with the feet positioned at the
head of the examining table and the knees slightly flexed (Buttaravoli and Leffler, 2012). Assess the
wound for length and depth, presence of debris or penetrating object, and signs of infection.
Examination findings consistent with cellulitis include:
• Localized pain or tenderness, swelling, and erythema at the puncture site (may be more obvious at
dorsum of the foot for plantar puncture wounds)
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• Possible fever
• Pain with flexion or extension of the extremity involved
• Decreased ability to bear weight
• For plantar puncture wounds, pain along the plantar aspect of the foot during extension or flexion of
the toes may indicate deep tissue injury, thus a higher risk of infection
Examination findings consistent with osteomyelitis-osteochondritis include:
• Extension of pain and swelling around the puncture wound and to the adjacent bony structures
• Exquisite point tenderness over the bone
• Fever
• Increasing erythema
• Decreased use of the affected extremity
Examination findings consistent with pyarthrosis (septic arthritis) include:
• Pain, swelling, warmth, and erythema over the affected joint
• Decreased range of motion and weight bearing of the affected joint
• Fever
Diagnostic Studies.
Plain film radiograph should be ordered if any of the following occur:
• A suspicion of a retained foreign object.
• There is a tremendous amount of pain at the site of the wound, localized tenderness is noted over the
wound, there is discoloration underneath the skin surface, or there is a palpable mass noted at or near
the wound entry site (Baddour, 2013).
• There was penetration of a joint space, bone or growth cartilage, or the plantar fascia of the foot.
• The puncture site has signs of infection and is from a nail injury.
• Most metal and glass foreign bodies can be seen on a plain radiograph. However, if the foreign
object is not radiopaque or if the x-ray is negative despite suspicion of foreign object in the
wound, computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI) are
useful diagnostic tools (Buttaravoli and Leffler, 2012).
• Bone scans are sensitive but not specific for osteomyelitis. Radiographs are specific, but findings
for osteomyelitis are noted late. Clinical examination and laboratory studies and imaging should
be considered early in the diagnosis of osteomyelitis (Erickson and Caprio, 2014).
• A complete blood count (CBC) and blood culture may be needed. An elevation in the white blood
cell count might indicate infection.
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