OBJECTIVES

General Objectives: At the end of the case presentation, the students will be able to acquire knowledge, basic skills and develop desirable attitudes through the utilization of the nursing process in the care of patient with lacerated wound.

Specific Objectives:

Specifically this case presentation aims to:

Define lacerated wound.

Discuss the Anatomy and Physiology of muscular system specifically theforearm.

Identify the causes, signs and risk factors in lacerated wound.

Assess client.

Identify nursing problems related to lacerated wound.

Plan and implement appropriate nursing interventions for client.

INTRODUCTION

A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns, or bone fractures). A wound may be caused by an act, such as a gunshot, fall, surgical procedure; by an infectious disease; or by an underlying condition; and in this case, by blast incident. Lacerations from blunt impacts may show bridging, as connective tissue or blood vessels are flattened against the underlying hard surface. The term laceration is commonly misused in reference to incisions. These wounds are torn, rather than cut. They have ragged, irregular edges and masses of torn tissue underneath. These wounds are usually made by blunt (as opposed to sharp) objects. A wound made by a dull knife, for instance, is more likely to be a laceration than an incision. Soft tissue injuries of the hand rarely are life threatening. However, the high incidence of disability from chronically painful or unstable joints is reflected by the fact that hand derangements account for 9% of all worker compensation claims. Bomb fragments often cause lacerations. Many of the wounds caused by accidents with machinery are lacerations; they are often complicated by crushing of tissues as well. Lacerations are frequently contaminated with dirt, grease, or other material that is ground into the tissue. They are therefore very likely to become infected. The costs for treating these injuries are considerable and include not only the direct costs of repair but also the indirect costs borne by the patient, his or her family, and society. These indirect costs include, for example, time off from work and costs incurred while seeking care. skin wounds of the hand, although commonplace, should not be trivialized. They must be handled with a methodical and thorough approach to optimize outcome and minimize morbidity. Antibiotic prophylaxis is indicated in human (including fight-bites) and cat bites and may be of benefit in dog bites as well. The use of antibiotics in other hand wounds is controversial but generally is best reserved for contaminated wounds and puncture wounds with possible retained foreign bodies. Hand wounds older than 6-8 hours should not be closed primarily because of an increased likelihood of infections. Irrigate and explore such wounds and apply a sterile dressing. Recheck the wound in 2-4 days, with consideration of delayed primary closure at 4days.

Definition of Terms Actin a contractile protein of muscle. Adenosine Triphosphate (ATP) a compound that is the important intracellular energy source; cellular energy. Creatinine Kinase an enzyme of the transferase class in muscle, brain and other tissues. Itcatalyzes the transfer of a phosphate group from adenosine triphosphate to creatinine, producing adenosine diphosphate and phosphocreatinine. Creatinine Phosphate an enzyme that increases in the blood levels when muscle damage has occurred, as in pseudohypertrophic muscular dystrophy. Endomysium the thin connective tissue surrounding each muscle cell. Epimysium the sheath of the fibrous connective tissue surrounding a muscle. Glycolysis breakdown of glucose to pyruvic acid; anaerobic process. Lactic acid the product of anaerobic metabolism, especially in muscle. Muscle a kind of tissue composed of fibers that are able to contract, causing and allowing movements of the parts and organs of the body. Muscular system all of the muscle of the body, including smooth, cardiac and skeletal or striated muscle, considered as and interrelated group. Perimysium the connective tissue enveloping bundles of muscle fibers. Pyruvate kinase is an enzyme involved in glycolysis. It catalyzes the transfer of a phosphate group from phosphoenolpyruvate (PEP) to ADP, yielding one molecule of pyruvate Radius one of the bones of the forearm lying parallel to the ulna, proximal end is small and forms a part of the elbow joint, distal end is large and forms a part of the wrist joint. Sarcomere the smallest contractile unit of muscle; extends from Skeletal muscle are composed of bundle of parallel, striated fibers under voluntary control.

ANATOMY AND PHYSIOLOGY Muscles are often viewed as the "machines" of the body. They help move food from one organ to another, and carry out our physical movement. There are approximately 639skeletal muscles in the human body. However, the exact number is difficult to define because different sources group muscles differently. Muscle (from Latinmusculus, diminutive of mus"mouse") is contractile tissue of the body and is derived from the mesodermal layer of embryonic germ cells. One of the most amazing things about the human body is the incredible range of movement and mobility it has. This day to day activity is accomplished by our muscles through the extraordinary and fascinating ability of converting chemical energy, energy stored in nutrients, into mechanical energy, energy of movement. Within the voluntary skeletal muscles, the glucose molecule can be metabolized anaerobically in a process called glycolysis which produces two ATP and two lactic acid molecules in the process (note that in aerobic conditions, lactate is not formed; instead pyruvate is formed and transmitted through the citric acid cycle). Biceps brachii two-headed muscle of anterior arm, proximal to radius, it flexes elbow and supinates forearm. Brachialis immediately deep to the biceps brachii. Anterior surface of distalhumerus, a major arm flexor. Brachioradialis superficial muscle of lateral forearm distal to humerus, synergist of brachialis in forearm flexion. Pronator teres anterior forearm; superficial to brachialis, distal humerus and choronoid process of ulna it pronates forearm. Flexor Carpi Radialis superficial that runs diagonally across forearm, is the medial epicondyle of humerus, it is the powerful wrist flexor abducts hands. Flexor Carpi Ulanaris superficial medial to flexor carpi medialis. The distal tohumerus and posterior to ulna. Powerful flexor of wrist and adduction. Flexor Digiturom Superficialis deeper muscle that overlain to all muscle of forearm, it flexes wrist and middle phalanges of second through fifth fingers.

PHYSIOLOGY
The three (skeletal, cardiac and smooth) types of muscle have significant differences. However, all three use the movement of actin against myosin to create contraction. In skeletal muscle, contraction is stimulated by electrical impulses transmitted by the nerves, the motor nerves and Moto neurons in particular.

All skeletal muscle and many smooth muscle contractions are facilitated by the neurotransmitter acetylcholine.

Muscular activity accounts for much of the body's energy consumption. All muscle cells produce adenosine triphosphate (ATP) molecules which are used to power the movement of the myosin heads. Muscles conserve energy in the form of creatine phosphate which is generated from ATP and can regenerate ATP when needed with creatine kinase. Muscles also keep a storage form of glucose in the form of glycogen. Glycogen can be rapidly converted to glucose when energy is required for sustained, powerful contractions.

Muscle cells also contain globules of fat, which are used for energy during aerobic exercise. The aerobic energy systems take longer to produce the ATP and reach peak efficiency, and requires many more biochemical steps, but produces significantly more ATP than anaerobic glycolysis. A majority of the muscle in the forearm help control a part of the arm. Among these is the Berachiodialis major-sound, palmaris long us-sound, and Flexor carpi radialis-sound.The name of the flexor carpi radialis is a good example of how muscles are named by their function and location. This muscle is named carpi because of the bones that it helps move, the carples. Also, the name of radialis is made by the bone that its attached to, the radius.