ROYAL HOBART HOSPITAL

EMERGENCY DEPARTMENT NURSING TREATMENT NOTES

Patient Name: LAHEY, Sarah Jane
UR Number: 2018-ED-07291830
Date of Birth: 13/03/1989
Age: 29 years
Date of Treatment: 29 July 2018
Treating Nurse: Jackson Roberts, RN (Senior Nurse)
Employee ID: RHH-RN-1847

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PATIENT DETAILS

Arrival Time: 17:30
Triage Completion: 17:43
Treatment Commenced: 18:43
Treatment Completed: 19:27

Triage Category: 3 (Urgent)
Presenting Complaint: Right hand laceration and head injury sustained during work-related fall
Allergies: NKDA
Tetanus Status: Current (2015)

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INITIAL ASSESSMENT (18:43)

Patient transferred to Bay 4 following triage by RN Thomson. Patient ambulatory, cooperative, alert and oriented x3. Presenting with right hand wrapped in blood-soaked fabric (appears to be grey cotton shirt sleeve), moderate bleeding controlled by pressure. Patient holding hand elevated against chest, protective posture noted.

Vital Signs on Assessment:

• BP: 138/86 mmHg
• HR: 84 bpm (regular)
• RR: 18 breaths/min
• Temp: 37.3°C
• SpO2: 98% room air
• Pain Score: 6/10 (hand), 7/10 (head) - patient initially understated, revised upon direct questioning

General Appearance:

Patient appears fatigued, slightly pale. Squinting against overhead lighting. Voice steady but quiet. Professional demeanor maintained throughout assessment - consistent with law enforcement background. Patient cooperative with all instructions but appears to be exercising significant self-control to manage pain/discomfort.

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WOUND ASSESSMENT - RIGHT HAND

Time: 18:48

Initial Examination:Removed makeshift bandaging (grey cotton fabric, heavily blood-soaked). Fabric had partially adhered to wound edges with dried blood. Removal required careful separation with saline-soaked gauze to prevent further trauma. Patient tolerated procedure well with minimal verbal response to discomfort.

Wound Description:

• Location: Right palm, extending from mid-palm obliquely toward base of thumb
• Length: Approximately 4.5cm
• Depth: Deep laceration penetrating dermis, subcutaneous tissue visible, no obvious involvement of deeper structures
• Edges: Clean, well-defined edges consistent with sharp glass laceration
• Bleeding: Moderate active bleeding upon removal of bandaging, easily controlled with direct pressure
• Debris: Minor debris noted - appears to be fabric fibers from makeshift bandaging, small amount of dried blood
• Sensation: Patient reports diminished sensation in immediate area, likely due to nerve involvement or trauma response
• Movement: Patient able to flex fingers with difficulty and significant pain. Full assessment deferred pending wound closure
• Circulation: Distal capillary refill <2 seconds, radial pulse palpable and strong

Mechanism Assessment:

Patient states injury sustained when catching self on broken window glass during fall at residential premises. Mechanism consistent with observed clean laceration pattern. No other defensive wounds or associated injuries to hand noted.

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WOUND IRRIGATION AND PREPARATION (18:52-19:03)

Procedure:

1. Positioned patient's hand on sterile field with adequate lighting
2. Explained procedure to patient, obtained verbal consent
3. Initial irrigation with 500ml sterile normal saline using 20ml syringe, 18g needle to create pressure stream
4. Thorough exploration of wound under irrigation to identify foreign bodies or debris
5. No glass fragments identified - wound track appears clear
6. Second irrigation with additional 250ml normal saline
7. Wound edges cleaned with gauze soaked in normal saline
8. Temporary sterile dressing applied with pressure whilst preparing for suturing

Patient Tolerance:

Patient remained calm and cooperative throughout irrigation. Minimal verbal response to discomfort. Maintained fixed gaze away from wound site - stated preference not to watch procedure. No signs of vasovagal response.

Assessment Post-Irrigation:

Clean wound with well-approximated edges suitable for primary closure. No evidence of tendon involvement, though patient reports pain with finger flexion. No obvious nerve damage to major branches, though localized numbness present (likely temporary). No foreign bodies detected. Wound suitable for interrupted sutures.

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LOCAL ANAESTHETIC ADMINISTRATION (19:05)

Agent: Lidocaine 1% without adrenaline
Volume: 8ml total
Route: Local infiltration

Procedure:

1. Explained burning sensation patient would experience during injection
2. Aspirated prior to injection to confirm no vascular penetration
3. Infiltrated wound edges using 25g needle - 4ml along each side of laceration
4. Patient tolerated injection well despite noting "significant burning" sensation
5. Allowed 5 minutes for anaesthetic to take effect
6. Tested sensation with gentle probe - adequate anaesthesia achieved

Patient Response:

Patient grimaced during injection but maintained composure. No adverse reactions noted. Sensation testing confirmed appropriate anaesthetic effect prior to suturing.

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SUTURING PROCEDURE (19:12-19:24)

Technique: Interrupted sutures
Material: 4-0 nylon (non-absorbable)
Number of Sutures: 6

Procedure Detail:

Suture 1 (19:12): Placed at mid-point of laceration to align wound edges and establish closure tension. Good approximation achieved.

Suture 2 (19:14): Placed 0.8cm proximal to first suture, toward base of thumb. Adequate tension for wound edge approximation without excessive tightness.

Suture 3 (19:16): Placed 0.8cm distal to first suture, toward mid-palm. Adjusted tension to match surrounding sutures.

Suture 4 (19:18): Additional suture placed between sutures 1 and 2 to ensure complete closure and even tension distribution along proximal wound edge.

Suture 5 (19:20): Placed between sutures 1 and 3 to close remaining gap in distal wound edge.

Suture 6 (19:23): Final suture placed at extreme distal end of laceration to ensure complete closure and prevent wound gaping.

All sutures placed with appropriate tension - sufficient to approximate wound edges without causing blanching or excessive tissue compression. Wound edges well-aligned throughout. No bleeding from suture sites. Excellent cosmetic result achieved.

Patient Tolerance:Patient reported sensation of pulling and pressure but no sharp pain throughout procedure. Maintained steady breathing, no signs of distress. Conversation maintained during procedure - patient responsive to questions, tone remained professional and controlled. Patient declined offer to see completed closure, stating she'd "rather not."

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POST-PROCEDURE ASSESSMENT (19:24)

Wound Inspection:

• All sutures intact and appropriately tensioned
• Wound edges well-approximated throughout length
• No bleeding from wound or suture sites
• No signs of haematoma formation
• Surrounding tissue pink and well-perfused

Neurovascular Check:

• Sensation: Patient reports continued numbness in immediate wound area (expected), normal sensation in fingertips
• Movement: Patient able to gently flex/extend fingers with moderate discomfort - ROM not fully assessed to avoid disrupting closure
• Circulation: Capillary refill <2 seconds, fingers warm, radial pulse present and strong

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DRESSING APPLICATION (19:25-19:27)

Dressing: Non-adherent pad, gauze wrap, conforming bandage

Procedure:

1. Applied thin layer of antibiotic ointment to sutured wound
2. Covered with non-adherent sterile pad
3. Wrapped with gauze padding for protection and absorption
4. Secured with conforming bandage - firm but not constrictive
5. Checked distal circulation post-dressing - fingers pink, warm, CRT adequate

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PATIENT EDUCATION

Wound Care Instructions Provided (Verbal and Written):

1. Keep dressing clean and dry for 48 hours
2. Elevate hand when possible to reduce swelling
3. Pain management: Paracetamol 1g every 6 hours as needed (no aspirin or ibuprofen due to bleeding risk)
4. Dressing change: Return to GP or RHH in 48 hours for dressing review
5. Suture removal: 10 days from today (8 August 2018) - can be done by GP or at RHH
6. Activity restrictions: Avoid heavy use of right hand, no immersion in water, no strenuous activity for 48 hours minimum

Signs/Symptoms Requiring Immediate Return:

• Increasing pain not controlled by paracetamol
• Redness spreading from wound edges
• Warmth, swelling, or discharge from wound
• Red streaks extending from wound site
• Fever >38°C
• Numbness or tingling that worsens or doesn't improve within 48 hours
• Loss of finger movement
• Any sutures breaking or wound opening

Patient verbalized understanding of all instructions. Written discharge information provided. Patient able to repeat back key warning signs appropriately.

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NURSING OBSERVATIONS AND CLINICAL NOTES

Patient presented as composed and professional throughout treatment despite significant injury. Pain tolerance appears high - patient consistently understated pain levels initially, requiring direct questioning to establish more accurate assessment. This is consistent with law enforcement training emphasizing stoicism and controlled presentation under stress.

Of note: Patient's mechanism of injury as reported (falling forward during search, catching hand on broken window glass) is consistent with observed laceration pattern. However, patient provided minimal elaboration when asked about circumstances of fall. Stated partner (Detective Karl Jenkins) was present at scene but uninjured. Patient appeared reluctant to discuss incident details beyond basic mechanism.

Patient's vital signs showed mild elevation in blood pressure and heart rate throughout treatment, consistent with pain and stress response. No signs of shock or significant blood loss. Patient remained alert, oriented, and appropriate throughout entire treatment period.

Wound characteristics consistent with sharp glass laceration - clean edges, minimal tissue damage beyond initial trauma. No complications during irrigation, anaesthesia, or suturing procedures. Final result: clean closure with good approximation, minimal scarring anticipated with appropriate follow-up care.

Recommendation: Patient to proceed to physician assessment for evaluation of reported head injury (concussion symptoms noted in triage). Suturing completed successfully, no concerns regarding hand wound closure at this time.

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REFERRAL TO DR. MONTGOMERY

Time: 19:27

Patient referred to Dr. Finn Montgomery (Head of Emergency) for neurological assessment of head injury. Patient reports:

• Significant headache (7-8/10)
• Light sensitivity (moderate)
• Nausea (moderate, controlled with antiemetic given during triage)
• Dizziness with position changes
• Denies loss of consciousness
• Denies vision changes beyond light sensitivity

Patient alert and oriented, no obvious neurological deficits noted during my assessment, but formal evaluation required given mechanism of injury and symptom constellation.

Handover notes: Patient stoic in presentation, likely minimizing symptoms. Recommend careful neurological screening and consideration of observation period given MOI and reported symptoms.

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Treatment Completed: 19:27
Documentation Completed: 19:35

Treating Nurse:

Jackson Roberts, RN

Senior Nurse, Emergency Department

Signature: J. Roberts
Date: 29 July 2018

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Form Authorization: ED-NURSING-TREATMENT-001
Distribution: Medical Record (Original), Physician Assessment (Copy), Patient Discharge Summary (Copy)