Traction - Pin Site Care And Management Following ...



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Canberra Hospital

Standard Operating Procedure

|Traction - Pins Site Care and Management Following Application of External Fixation, Ilizarov Fixator and Skeletal Pins Used for |

|Traction |

Purpose

To prevent infection and excess skin granulation around external pin sites by providing appropriate pin site care.

Scope

This document pertains to patients admitted to the Canberra Hospital requiring pin site management, and associated fixation and traction management.

This document is applicable to:

• Medical Officers

• Nurses who are working within their scope of practice (Refer to Nursing and Midwifery Continuing Competence Policy)

• Student nurses under direct supervision.

Equipment

• Alcohol based hand rub (ABHR)

• Basic dressing pack

• Normal saline

• Gauze swabs

• Sterile corks

• Clean gloves

• Sterile gloves

• Personal Protective Equipment (PPE) including safety goggles / shield

• Antibiotic ointment (optional)

• Split foam dressing (optional)

• Oxygen tubing (optional)

• Wound swab (optional)

• Clinical waste receptacle

• General waste receptacle.

Procedure

The initial post-op dressing remains intact for 24 hours post insertion of the pins, after which pin site dressing/s are attended daily.

For patient comfort and early assessment of potential problems, it is recommended that the wound be inspected within 24 hours and on a daily basis. All pin sites should be redressed after 24 hours as there is likely to be exudate. Pin site infections can result in osteomyelitis and delayed fracture healing.

External fixation is prescribed and applied by the medical officer.

External skeletal pins are used for external fixation or for skeletal traction.

External fixators will be used when the fracture is comminuted (many fragments) and compound (open) and involving a wound, which connects directly with the fracture site.

Attending Pin Site Dressing

1. Attend hand hygiene before touching the patient by either hand washing or using ABHR

2. Explain procedure and obtain patient consent

3. Ensure privacy

4. Attend hand hygiene by either hand washing or using ABHR

5. Don clean gloves and goggles / shield

6. Remove old dressing, warmed normal saline solution may be needed if dressing had adhered to wounds and/or pins

7. Discard waste in clinical waste receptacle

8. Remove gloves

9. Attend hand hygiene by either hand washing or using ABHR

| |

|ALERT: Aseptic technique must be rigorously maintained at all times with pin site care. |

|Follow principles outlines in the Standard Operating Procedure: Basic Wound Dressing Technique |

10. Assemble equipment on cleaned dressing trolley

11. Discard packaging in general waste receptacle

12. Attend hand hygiene by either hand washing or using ABHR

13. Don Sterile gloves

14. Clean each pin site with a non–shredding material such as gauze and warm normal saline. A new piece of gauze is used for each pin

15. Observe general circulation of the limb

| |

|ALERT: Alcohol and iodine based products should be avoided due to accelerated corrosion of the metal and skin staining. Alcohol is |

|damaging to the capillary bed when it drips into the wound. Hydrogen peroxide should be avoided as it is damaging to tissue. |

16. Remove any crusts that may have formed around the pins using gauze and warm normal saline

• Rationale: Gentle removal of the crusts allows visualisation of the wound and encourages free drainage of exudate, which may harbour infection if allowed to collect below the skin

17. Leave the wound dry after cleaning

• Rationale: Moisture encourages colonisation

18. Observe the wound daily for redness, inflammation, odour, excess ooze and/or purulent ooze

19. Provide the patient with education to observe and report these signs

20. Discard waste in clinical waste receptacle

21. Remove gloves

22. Attend hand hygiene be either hand washing or using ABHR

23. Document the procedure and findings in the Clinical Care Plan and Clinical Record and Wound Assessment Chart (Wound Basic Dressing Technique SOP”).

Important Considerations and Wound Observations

1. Where serous ooze persists or pus is present, a wound swab is attended and the Medical Officer notified (Refer to the Standard Operating Procedure: Wound Swab)

2. Antibiotic ointment may be prescribed on the patient’s medication chart by the Medical Officer. If applying an antibiotic ointment ensure that a new swab is used for each pin site

3. Ensure the skin around the pin remains mobile by massaging the skin in a circular motion on either side of the pin. Do not touch the pin site

• Rationale: Massaging the skin around the pin site allows free drainage of any ooze. This is useful for mono-frames, particularly when applied to the pelvis

4. Observe the pin site for over-granulation growing up the pin site or tenting of the skin around the

pin

5. Where over-granulation has occurred or exudate is present, place a trimmed split foam dressing

over the pin site

• Rationale: This applies a small amount of pressure on the surrounding tissue to prevent further tenting.

6. Where there is increased tenderness or pain at the pin site alert the medical officer

7. Observe the pin for any movement and ensure pin attachments are secure

8. Apply sterile corks to sharp pin points that may need protecting

9. Oxygen tubing is applied to the pin points extending from the main frame to protect the linen and

blankets of the patient’s bed

10. Educate the patient on the importance of good pin site care.

11. Provide written instructions for the patient

12. On discharge arrange for community nursing care if the patient and/or carer is unable to care for the pin sites

|Note: The patient is able to shower normally. The external fixator can be left unprotected whilst showering provided there are no other |

|dressings or wounds. |

13. Document the procedure and findings in the Clinical Care Plan and Clinical Record and Wound Assessment Chart (Refer to the Standard Operating Procedure: Basic Wound Dressing Technique)

Evaluation

Outcome Measures

The patient’s pin sites of the external fixators are observed and managed, with minimal discomfort and no complications or adverse events. Patients are well informed of requirements, and documentation is evident in the patient’s clinical record.

Method

All incidents related to Pins Site Care and Management Following Application of External Fixation, Ilizarov Fixator and Skeletal Pins Used for Traction are reported via the Clinical Incident Reporting System Riskman & Staff Accident Incident Reporting (SAIR). Incidents are reviewed and corrective actions are reported via relevant departments in line with continuous quality improvement processes.

Related Legislation and Standard Operating Procedures

Health Directorate Infection Prevention and Control Policy

Health Directorate Waste Management Policy

Canberra Hospital Infection Control- Personal Protective Equipment Policy

Nursing and Midwifery Continuing Competence Policy

Wound Basic Dressing Technique SOP

Wound Management Standards Policy

Wound Swab SOP

Wound Assessment Form

References

ACT Health (2008) The Canberra Hospital, Acute Care Practice Manual, External Skeletal Pin: Site Care ©. The Joanna Briggs Institute.

Cavusoglu, A. T., Serhan, M., Inal, S., Ozsoy, M. H., Ercan, V. & Sakaogullari, A. (2009). Pin site care during circular external fixation using two different protocols. Journal of Orthopaedic Trauma, 23(10), 724-730.

Chan, C. K., Saw, A., Kwan, M. K. & Karina, R. (2009). Diluted povidone-iodine versus saline for dressing metal-skin interfaces in external fixation. Journal of Orthopaedic Surgery, 17(1), 19-22.

Holmes, S. B., Brown, S. J. & Pin Site Care Expert Panel. (2005). Skeletal pin site care: National association of orthopaedic nurses guidelines for orthopaedic nursing. Orthopaedic Nursing, 24(2), 99-107.

Lethaby, A., Temple, J. & Santy, J. (2008). Pin site care for preventing infections associated with external bone fixators and pins (Review). The Cochrane Library 2008, 4. Retrieved April 10, 2010, from the Cochrane Collaboration database.

Patterson, M. M. (2005). Multicenter pin care study. Orthopaedic Nursing, 24(5), 349-360.

Santy, J. (2000) Nursing the patient with an external fixator. In Nursing Standard. Vol. 14. No. 31. Pg 47-54.

Santy, J., & Newton-Triggs, L. (2006) A survey of current practice in skeletal pin site management. Journal of Orthopaedic Nursing. Vol. 10. Pg 198-205.

Stanley, C. (2004) Extending the role of nurses in staff development by combining an organisational change perspective with an individual learner perspective. In Journal for Nurses in Staff Development. Vol. 20. No. 2. Pg 83-89.

The Canberra Hospital and Community Health Wound Management and Pressure Injury Prevention Committee. (2007). Wound Management Guide to Dressing Products 2007. Canberra: Author.

Temple, J. and Santy, J. Pin site care for preventing infections associated with external bone fixators and pins (review). Cochrane Database of Systematic Reviews 2004, issue 1. Art. No.: CD004551. DO1.1002/14651858.CD004551.

Trofino. A.J. (2000) Transformational leadership: moving total quality management to world class orgaisations. In International Nursing review. Vol. 47. Pg 232-242

Ward, P. (1998) Care or skeletal pins: a literature review. In Nursing Standard. Vol. 12. No. 39. Pg 34-38.

W-Dahl, A. & Toksvig-Larsen, S. (2009). Undisturbed theatre dressing during the first postoperative week. A benefit in the treatment by external fixation: a cohort study. Strat Trauma Limb Reconstruction, 4, 7-12.

Wu, S. C., Crews, R. T., Zelen, C., Wrobel, J. S. & Armstrong, D. G. (2008). Use of chlorhexidine-impregnated patch at pin site to reduce local morbidity: The ChIPPS pilot trial. International Wound Journal, 5(3), 416-422.

Disclaimer: This document has been developed by ACT Health, the Canberra Hospital specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility whatsoever.

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