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Pain
Pallor with cyanosis to the lips
Headache
Bleeding
Objective Data
Head
Hair
Face
Problem Identified
1. Acute pain
2. Impaired physical
mobility
Neck
Thorax/Lungs
Back
Eyes
Dilated pupils
Bruising (discoloration) around the eyes
Unequal pupil size
Abnormal eye movements
Ears
Bruising (discoloration) behind the ears (mastoid process)
Blood or fluid (cerebrospinal fluid) leakage from the ears
Nose and Sinuses
Blood or fluid (cerebrospinal fluid) leakage from the nose
Fractures of the maxilla
Teeth does not align properly
Difficulty opening mouth
Numbness in the lip and chin
1. Acute pain
2. Body image
disturbance
1. Acute pain
2. Nutrition, altered:
less than body
requirements
3. Impaired verbal
communication
1. Acute pain
1. Impaired gas
exchange
2. Acute pain
3. Ineffective Airway
Clearance
4. Ineffective Breathing
Pattern
1. Acute pain
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Cardiovascular/
Peripheral Vascular
Lymphatic
GIT
GUT/Reproductive
1. Acute pain
2. Body image
disturbance
1. Ineffective tissue
perfusion
2. Decreased cardiac
output
1. Acute pain
2. Altered pattern of
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Musculoskeletal
Integumentary
Neurologic
urinary elimination
1. Acute pain
2. Impaired physical
mobility
3. Activity intolerance
1. Impaired skin
integrity
2. Risk for infection
1. Anxiety
2. Body image
disturbance
3. Fear
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1. Fatigue
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