湿性愈合模式在肛周脓肿致坏死性筋膜炎患者伤口护理中的应用

目的：探讨湿性愈合模式在肛周脓肿致坏死性筋膜炎患者伤口护理中的应用及效果。方法回顾性分析、总结2010年1月-2013年5月收治的3例肛周脓肿致坏死性筋膜炎患者伤口治疗及护理经验。结果通过开放引流、瘘管科学处理,有效清创、控制感染、防止血流感染,合理固定、提高生活质量,科学营养支持、促进肉芽生长创面愈合,人文关怀、多学科协作促进康复等湿性愈合伤口护理,所有患者均愈合,无病死、致残。结论湿性愈合伤口护理在急性坏死性筋膜炎的创面治疗中可以促进伤口愈合、降低医疗风险,安全可行。     

Importance of Health History in Diagnosis of an Acute Illness

The following Case Challenge presents the clinical course of a febrile infant who presented with her parents to the emergency department in an acute care hospital. The febrile infant requires prompt evaluation, diagnosis, and treatment. Key components of a patient’s health history, including social and environmental exposures, can help clinicians in formulating and prioritizing diagnoses. This Case Challenge demonstrates a clinical scenario in which the health history aids the medical team in initiating empiric treatment. The case also demonstrates that multidisciplinary care is essential to improving short- and long-term outcomes for patients with acute illnesses.     

Nursing consideration in acute spinal cord injury

The nurse who cares for the SCI patient during the acute phase provides the assessment, implementation of routine care, and critical interventions necessary for survival. Although this group of patients requires the coordinated efforts of a multidisciplinary team for rehabilitation, it is the ICU nurse during the acute phase of care who lays the groundwork necessary for the patient to attain an optimal level of function. Care of the acutely ill SCI patient is a challenge that constantly demands innovative, individualized professional nursing care.     

Traumatic spinal cord injury: an acute care rehabilitation perspective

Traumatic spinal cord injury (SCI) can have a devastating effect on the patient, family members, and acute care staff. A multidisciplinary team effort is essential for the psychosocial support of the patient and family through the injury process. SCI rehabilitation management in the acute care setting will be reviewed along with the process for selecting an appropriate rehabilitation facility.     

Acute care management of spinal cord injuries

Meeting the health care needs of the spinal cord-injured patient is an immense challenge for the acute care multidisciplinary team. The critical care nurse clinician, as well as other members of the team, needs to maintain a comprehensive knowledge base to provide the care management that is essential to the care of the spinal cord-injured patient. With the active participation of the patient and family in care delivery decisions, the health care professionals can help to meet the psychosocial and physical needs of the patient/family unit. This article provides an evidence-based, comprehensive review of the needs of the spinal cord-injured patient in the acute care setting including optimal patient outcomes, methods to prevent complications, and a plan that provides an expeditious transition to rehabilitation.     

Special nursing considerations

Caring for a critically ill patient with cancer requires another dimension of care when compared with caring for patients in a general ICU. The oncology critical care staff deals with an acute event and with the multidimensional aspects of care of a patient with a cancer diagnosis. Goals of care include a reduction in the number and severity of disease- and treatment-related adverse sequelae. Effective management requires a multidisciplinary approach to care. Skilled and knowledgeable care and communication among all members of the team are essential to prevent, minimize, and treat these symptoms and to achieve optimal patient outcomes.     

Necrotizing fasciitis: a dramatic surgical emergency.

OBJECTIVES: Necrotizing fasciitis is a challenging and potentially lethal disease; early diagnosis is of paramount importance and aggressive multidisciplinary treatment is mandatory. Overall mortality rates of 33-73% have been reported. The aim of this study was to report the experience with necrotizing fasciitis of an emergency surgery department. METHODS: From October 1995 to December 2001 we observed 11 cases of necrotizing fasciitis. The patients were five men and six women, with ages ranging from 33 to 80 years. RESULTS: Triggering aetiological factors were found in eight cases. In all patients a multidisciplinary approach was utilized. Every patient had a daily surgical debridement of the necrotic areas in the operating room. Polyantibiotic therapy was performed, and was changed according to culture results. After surgery, nine patients were submitted to hyperbaric oxygen therapy. Seven deaths (63.6%) were observed: two cases of pulmonary embolism and five cases of septic shock. Four patients survived; three had a complete recovery with progressive healing of the wounds, whereas one patient had severe impairment of the motility of the affected hand. The mean interval between the onset of symptoms and hospital admission was 5.4 days; for patients who ultimately died it was 7.3 days, whereas for patients who ultimately survived it was 2 days (P<0.05); moreover these patients were significantly younger than those who died (P<0.05). CONCLUSION: The treatment for necrotizing fasciitis is a combination of surgical debridement, appropriate antibiotics and optimal oxygenation of the infected tissues. However, the mortality for this disease is quite high, and is related to late diagnosis and advanced age. Necrotizing fasciitis must be considered a true dramatic surgical emergency.     

Transdisciplinary approach: an atypical strategy for improving outcomes in rehabilitative and long-term acute care settings.

In the rehabilitation and long-term acute care settings, an atypical strategy has emerged in the past few years whereby the central focus is on improving patient care through a team approach in which responsibilities are shared and the normal boundaries of the healthcare professions blurred. This article provides a conceptual analysis of this unique, transdisciplinary approach to care delivery. Differentiation between interdisciplinary, multidisciplinary, and transdisciplinary techniques is provided through case scenarios. Defining attributes, necessary antecedents, and the many possible positive outcomes from the transdisciplinary approach to practice is discussed. This concept analysis defines for the rehabilitation or long-term acute care nurse a method that can be used to redesign care delivery, to promote improved patient outcomes, and to achieve a cohesive team environment.     

Streptococcal infection and necrotizing fasciitis--implications for rehabilitation: a report of 5 cases and review of the literature

Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.     

Dermatologic emergencies

Life-threatening dermatologic conditions include Rocky Mountain spotted fever; necrotizing fasciitis; toxic epidermal necrolysis; and Stevens-Johnson syndrome. Rocky Mountain spotted fever is the most common rickettsial disease in the United States, with an overall mortality rate of 5 to 10 percent. Classic symptoms include fever, headache, and rash in a patient with a history of tick bite or exposure. Doxycycline is the first-line treatment. Necrotizing fasciitis is a rapidly progressive infection of the deep fascia, with necrosis of the subcutaneous tissues. It usually occurs after surgery or trauma. Patients have erythema and pain out of proportion to the physical findings. Immediate surgical debridement and antibiotic therapy should be initiated. Stevens-Johnson syndrome and toxic epidermal necrolysis are acute hypersensitivity cutaneous reactions. Stevens-Johnson syndrome is characterized by target lesions with central dusky purpura or a central bulla. Toxic epidermal necrolysis is a more severe reaction with full-thickness epidermal necrosis and exfoliation. Most cases of Stevens-Johnson syndrome and toxic epidermal necrolysis are drug induced. The causative drug should be discontinued immediately, and the patient should be hospitalized for supportive care.     

Responding to an Emerging Need: Implementing Telehealth in Acute Hospital Rehabilitation

This article outlines a multidisciplinary approach to implementing a telehealth program in the acute care hospital setting during the coronavirus disease 2019 (COVID-19) pandemic. Telehealth has been used in many practice areas, although it can be a particular challenge to establish in an acute care hospital given the fast-paced environment. However, the COVID-19 pandemic presented a unique situation. In-person treatment interactions became increasingly high risk for both patient and provider, and there was an emerging need to conserve personal protective equipment and limit exposure. In response to these developments, physical therapists, occupational therapists, and speech language pathologists treating an adult population turned to telehealth to supplement in-person treatment. This article outlines the clinical reasoning and practical application to implementing a telehealth program in an acute care hospital and includes regulations, identified successful strategies, barriers, considerations, decision-making algorithms, and discipline-specific interventions.     

Emergency amputation necessitated within 24 hours by a human bite: a case report

We herein review and analyze the diagnosis, treatment, and outcome of a severe infection caused by a human bite. A 68-year-old man was bitten on the forearm by a 3-year-old child. Rapid progression of infection, severe local and systemic poisoning, and diverse clinical manifestations were observed at presentation. Based on the medical history, physical signs, imaging examinations (X-ray films, color Doppler ultrasound, and computed tomography), laboratory examinations, and multidisciplinary consultation, the patient was diagnosed with gas gangrene or gas gangrene-like changes. Twenty-four hours after the injury, an emergency amputation was performed (open amputation with wound closure after 1 week). After the operation, the patient was sent to the intensive care unit for isolation and further anti-infection and anti-shock treatments. His condition gradually improved after treatment and he was discharged without further complications. Bacteriological and pathological examinations indicated Aeromonas hydrophila infection leading to extensive necrotizing fasciitis of the limb and severe systemic poisoning. In addition, pre-existing myelodysplastic syndrome progressing to acute myeloid leukemia was identified as a possible predisposing factor. Human bites can cause serious infections requiring timely treatment, particularly in patients with predisposing comorbidities.     

Effects of nurse caring behaviours on family stress responses in critical care.

Although nurses realise the importance of the family in holistic care of the patient, often they are reluctant to integrate family into the ICU environment. The family role in patient healing has been minimised. There is incongruence in nurses' assessments and families' perceptions of what constitutes caring behaviours. Traditionally ICUs have been primarily patient focused; changing to family-centred will require attitude changes and a multidisciplinary team approach to care. Studies have shown families to be stressed and at significant risk for maladaptation when acute illness or trauma strikes. Nurses potentially may alter family stress responses through caring behaviours, and a family-centred approach to care.     

1例急性ST段抬高型心肌梗死患者并发癫痫的护理

总结1例急性ST段抬高型心肌梗死患者并发癫痫的护理经验。护理主要内容如下：组建多学科团队,制订最佳诊疗护理方案;识别癫痫发作,实施急救护理;加强病情观察和护理,预防南北综合征;实施个性化渐进性康复训练,预防ICU获得性衰弱。经过精心的治疗及护理,患者好转出院。     

Necrotizing fasciitis: pathogenesis and treatment

Necrotizing fasciitis is a rapidly progressive, life-threatening infection and a true infectious disease emergency. Despite much clinical experience, the management of this disease remains suboptimal, with mortality rates remaining approximately 30%. Necrotizing fasciitis rarely presents with obvious signs and symptoms and delays in diagnosis enhance mortality. Therefore, successful patient care depends on the physician's acumen and index of suspicion. Prompt surgical debridement, intravenous antibiotics, fluid and electrolyte management, and analgesia are mainstays of therapy. Adjunctive clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulin are frequently employed in the treatment of necrotizing fasciitis, but their efficacy has not been rigorously established. Improved understanding of the pathogenesis of necrotizing fasciitis has revealed new targets for rationally designed therapies to improve morbidity and mortality.     

Use of an acute spinal cord injury clinical pathway

Phased outcome clinical pathways can be useful in the management of neurotrauma patients in the acute care setting. By developing multidisciplinary plans of care that focus on patient and family outcomes and not arbitrary points in time, hospitals can provide quality care to trauma patients that is both appropriate and cost effective. In fact, this type of plan for SCIs can be expanded on and used across the health care continuum from prehospital to community reintegration. Providing collaborative quality care will result in improved outcomes for both patients and health care institutions.     

Treatment of the patient with acute myocardial infarction: reducing time delays

There is a critical relationship of time to treatment and myocardial salvage in the patient with acute myocardial infarction (AMI). The challenge lies in developing a process that minimizes delays in assessment and initiation of reperfusion therapy. Three target areas were identified-time to EKG. thrombolytic therapy, and primary PTCA. A multidisciplinary team reviewed the existing standard of care and identified critical areas that were causing delays. An emergency department algorithm was developed to minimize delays, while data analysis tracked our progress. A collaborative multidisciplinary effort can reduce delays in the treatment for the patient with AMI.     

The Cardiac Surgery Advanced Practice Group: A Case Study of APN and PA Collaborative Practice

In the United States, more than 600,000 surgeries for cardiac disease are performed annually, accounting for millions of dollars in health care expenses. The rise in patient acuity levels from comorbid factors is contributing to these costs. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide advanced therapies while decreasing the costs associated with that care. Advanced practice nurses (APNs) and physician assistants (PAs) are able to work with multidisciplinary groups to provide comprehensive care and decrease costs. The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting. The origins and benefits of this role and future for this model are addressed.     

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BackgroundThere is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.ObjectivesThe objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.Methods, design, setting, and participantsThis was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.Main outcome measuresThe main outcome measures were knowledge of post–intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.ResultsThe overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.ConclusionThere are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.     

Managing the threat of methicillin-resistant Staphylococcus aureus in home care

Severe fatal complications such as pneumonia, cutaneous abscesses, empyema, necrotizing fasciitis, and sepsis can result from methicillin-resistant Staphylococcus aureus (MRSA) even for healthy people. An overview of managing the threat of MRSA in home care is presented. The home healthcare nurse can be proactive with MRSA infections by following and teaching strict medical asepsis while assessing the slightest signs and symptoms indicating that a patient is deteriorating or not responding to the prescribed antibiotic or wound care. This article aims to increase awareness of community-acquired (CA)-MRSA, to offer suggestions for preventing CA-MRSA, and to describe methods for managing this infectious process in the home.