Moulage: Pus- Thick, Odorous, Wound Exudate
Moulage: A Collaboration of Experts
2 Tbsp. waterbased lubricating gel
2 tsp. of petroleum jelly
(SIM-Safe) yellow, colorant
(SIM-Safe) brown, colorant
Odor: (SIM-Safe) "Decaying matter"
Supplies: (Shop www.moulageconcepts.com for all your moulage needs!)
Palette knife or utensil
Spray bottle, water
Post Surgical Infection
Simulation Suite Location: Patient bedside on surgery floor. Using an adult simulator, create pallor and sweat on the face of the patient. To create pallor: Using a make-up sponge, gently blot white makeup over the face, neck and upper chest area of the simulator, allowing some natural skin to show through. Create eye reddening around the upper and lower eye lids. To create Eye Reddening: Using SIM-Safe red make-up, carefully apply red colorant to upper and lower eye lash line using a small paint brush or cotton swab.
Adhere surgical dehiscence wound to abdomen. Using a syringe filled with odorous pus, apply large beads of mixture to incision site of wound. To fill wound: Carefully, place tip of syringe inside the suture line. Applying gentle pressure, expel contents inside the dehiscence wound, continuing to apply gentle pressure to the applicator until little mounds form through the suture line. Carefully place a 4 x4 wound dressing over the incision, pressing softly to adhere pus to the underside of the dressing and taping in place. Create beads of sweat on the simulators skin by applying a light mist of sweat mixture to the forehead, chin, and upper lip.
Patient Chart Include chart documentation that supports surgical procedure, history, initial labs and increasing WBC and fever. Use in Conjunction With (simulated): Skin reddening Serosanguinous drainage
Surgical dehiscence wound
What the experts have to say:
Simulation Scientist: Infectous Pus or MRSA: Unmasking the Malady
The symptoms of Methicillin-resistant Staphylococcus aureus, (MRSA) often masquerade as relatively innocuous skin conditions such as spider bites, heat rash, razor burn, ingrown hairs or acne. MRSA misdiagnosis can have dangerous or even fatal consequences. Failure to recognize and properly treat a patient infected with MRSA may lead to inappropriate delivery of care.
The infected individual may remain in the general population and infect family, coworkers, other patients or staff.
The patient may be prescribed antibiotics that have little effect and allow proliferation of the infection.
Left untreated, the infection will progress, resulting in more serious disease.
Infections may lead to serious complications with co-morbidities and can quickly prove lethal.
MRSA infections are the most frequent and often the most invasive pathogens associated with our most vulnerable patient populations.
Rapid spread of community-associated MRSA is characterized by outbreaks of cutaneous infections in healthy individuals.
CDC estimated over 54,200 hospitalizations annually for MRSA infections in 1999–2000. 90,000 invasive infections due to MRSA occurred in the United States in 2005. These numbers are increasing at an alarming rate.
Recognize the Disguise: MRSA Simulation Simulations should include many different presentations in which MRSA should be considered.
apparent “spider bite”
rythematous skin with red papules and central pustules
single lesions on the extremities or multiple “boils”
fluctuance-wavelike motion beneath the lesion when pressure is applied
impetigo and necrotizing fasciitis, “track” marks (frequently among IV drug users)
fever, low BP and shortness of breath (indicators of systemic infection)
MRSA should be considered in the differential diagnosis of any skin and soft tissue infections (SSTIs) and some diseases not typically associated with S. aureus (purpura fulminans, necrotizing fasciitis). When a patient presents with a chief complaint of “spider bite” the clinician should immediately suspect S. aureus infection. MRSA should also be considered in the differential diagnosis of other syndromes associated with S. aureus infection, such as endocarditis, pneumonia, sepsis, osteomyelitis, septic arthritis. Strategies for Clinical Management of MRSA in the Community: Summary of an Experts’ Meeting, Centers for Disease Control and Prevention, March 2006
Invasive methicillin-resistant Staphylococcus aureus infections in the United States. Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, Harrison LH, Lynfield R, Dumyati G, Townes JM, Craig AS, Zell ER, Fosheim GE, McDougal LK, Carey RB, Fridkin SK, Active Bacterial Core surveillance (ABCs) MRSA Investigators JAMA. 2007;298(15):1763
Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clinical Infectious Diseases. 2006;42:S82-9.
Noskin GA, Rubin RJ, Schentag JJ, et al. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998–2003).Clin Infect Dis 2007;45:1132-40.
Rossney AS, Herra CM, Brennan GI, et al. Evaluation of the Xpert Methicillin-ResistantStaphylococcus aureus (MRSA) assay using the GeneXpert Real-Time PCR platform for rapid detection of MRSA from screening specimens. J Clin Microbiol . October 2008;3285-3290.
Dolinger DL, Jacobs AA. Molecular diagnostics and active screening for health care-associated infections, Lab Medicine. 2011;42(5):267-272. Marilyn C. Roberts, Olusegun O. Soge, David No, Nicola K. Beck, John S. Meschke. Isolation and characterization of methicillin-resistant Staphylococcus aureus from fire stations in two northwest fire districts. American Journal of Infection Control, 2011
Nathwani D, Morgan M, Masterson RG, et al. Guidelines for practice for the diagnosis and management of methicillin-resistant Staphylococcus aureus (MRSA) infections presenting in the community. J Antimicrob Chemother. May 2008
Catriona D. Graham, PhD. Medical Simulation Scientist Catriona Graham holds a Ph.D. In biomedical research with a concentration in neuroscience and is completing her M.S. in pharmacology and toxicology. She is an Advanced Clinical Simulation Fellow at the Dayton Veterans Administration Medical Center. Dr. Graham is a dedicated educator with 20 years of experience and is currently faculty instructor of Anatomy and Physiology.
Infectious Pus or MRSA? MRSA in the community is largely limited to skin infections. However, hospitalized patients are at increased risk for more life threatening complications from this antibiotic-resistant organism. The sight of this draining and dehiscing wound, especially with the general appearance of a the patient as described, should trigger more than concerns about general wound care. For healthcare personnel this is a red flag to act. The nurse should communicate with the team, and consider who all the stakeholders truly are. A provider needs to order cultures and would likely institute antibiotic therapy. This scenario provides rich opportunities for participants to explore! Here are some potential pre or post-simulation projects:
Think about the interprofessional team by brainstorming as a group. Who are stakeholders? Providers? Dietary or housekeeping personnel? Visitors? The quality and safety nurse? Provide rationales. (QSEN Teamwork and Collaboration)
Find 3 online resources to learn more about MRSA. Discuss if these are quality sources of information and why or why not.(QSEN Evidence Based Practice)
How might family be included in the patient care? (QSEN Patient-Centered Care)
Seek information on the outcomes of care for patients that have had MRSA infections at a local facility (QSEN Quality Improvement)
Sara Manning, MS, RN, CHSE Coordinator of Clinical Simulation Education NLN Simulation Leader Assistant Professor of Nursing
Primary Patient-Adult patient: Appear disconnected from the staff and confederate, focus on your wound. Pause before answering questions to appear unfocused. In staff does not properly assess your wound, speak about pain and that there was fluid leaking from the site. To increase the realism, lightly soak the gown and pillow on the patient bed to simulate a high fever.
Confederate: Instruct confederate to verbalize to staff the wound if participants do not assess properly. Add to the sense of urgency by stating; patient does not feel well, feels very warm. Ask if they have taken a temperature. Patient Chart: (Add) Include patients weight in kg, and oral or rectal temperature (depending on patients age). Be sure chart reflects proper procedure for the wound shown. Setup up location with wound care supplies, anticipate any medications or special equipment that can be requested.
Tip: This simulation works especially well on our high-fidelity simulators. Using a high-fidelity simulator allows the specialist to engage the participants with answering questions and highlighting the patient compliant. Care should be made to adhere wound in accordance with the procedure and position on the patient chart while maintaining proper barriers to protect the simulator. Pre-set temperature (either on the monitor or given when asked) to reflect a change in patients status. I have found creating a wound using reusable materials will allow for faster setup for future simulations.
Simulation Specialist David is currently working as a Simulation Specialist with Cedars-Sinai Medical Center in Los Angeles, California and is a member of the simulation certification group CHSOS. He has over 2 years experience in medical simulation programs, as well as 6 years clinical experience working pre-hospital EMS and in the Emergency Department
On a masonite board, combine waterbased gel and vaseline. Stir the gel mixture thoroughly with the back of the palette knife to blend, creating a milky-white color.
Activate your SIM-Safe color stix: Using your water spray bottle, lightly spray your SIM-Safe stix from a 6" distance (Spray water only 1-2 times on colorant). This will activate the make-up creating a cream based product that is ready to use. When make-up is ready, swirl the color stix through the gel product, depositing color. Make-up stix will deactivate in approximately 15 seconds. Depending on the stage of the infectious process, additional colors such as brown may be applied to deepen the color and highlight wound infection progression.
Odor: Using SIM-Safe Decaying Flesh odor from our Nursing Line, apply 2-3 drops of odor into the pus mixture, stirring well to blend.
Create multiple colors of pus at one time: Following the recipe directions, multiple the amounts to create a large batch of milky-white pus. Divide mixture and apply SIM-Safe colorants as desired to each infectious process. Store pus mixtures in separate 20cc syringes with cap. Odors can be applied right before the training scenario.
In a Hurry? Simulated pus can be altered by color, made in advance and stored in the refrigerator until ready to use. Cleanup and Storage Gently remove dehiscence wound from the skin of the simulator. Store wound with simulated pus on a waxed paper–covered cardboard wound tray. Wounds should be stored side-by-side, but they should not touch to avoid cross-color transference. Loosely wrap wound trays with plastic wrap and store flat in freezer or according to simulation center policy. Using a soft clean cloth remove remaining product residue from the skin per manufacturers directions.
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Bobbie Merica is a medical/trauma moulage expert, author and CEO of Moulage Concepts, an nationwide moulage company specializing in training, supplies and education. Utilizing best practice techniques, Bobbie's teaching methods have simplified the complex, enabling everyone to create Moulage that is quick, cost effective and convincing. Get her free tutorial blog with expert weigh-in at www.moulageconcepts.com/blog and join us in creating moulage that looks, feels, sounds, and even smells like the real thing!
Recipe are referenced from Medical Moulage- Making Your Simulations Come Alive.
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Author: Bobbie Merica, Publisher: FA Davis 2011
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