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Contusion
Cequina, Patricia Joy
Macias, Daisy Anne
De Guzman, Louie Angelo
Baek, Kum Bee
Introduction
Social History
Patient ABC is a 14 years old male. Born on
Developmental Task
Developmental Task
Ego identity vs. Role Confusion
(Adolescence 12 -18 )
In this stage the child learns the roles he will occupy as an adult, re
exam in identity and try to find our who he or she is the two identities
involved are sexual and occupational.
Theorist
Erik Erikson (1902-1994)
Psychosocial Theory
Status
Positive resolution our patient has established what he wanted to be
when he grows up, he sees himself as a police man in the society,
which means he knows what he wants to become as an adult. And also
he has a girlfriend therefore he is not confused of his sexual identity.
Developmental Task
Developmental Task
Genital stage
(Puberty - Adulthood )
In this final stage sexual urges reawaken and are directed to an
individual outside the family circle. Unresolved conflicts surface during
adolescence. Once the individual resolves conflicts, he or she is then
capable of having a mature adult sexual relationship .
Theorist
Sigmund Freud
Psychosexual Theory
Status
Going towards positive resolution since the patient is just 14 years old
he just entered this stage he is still starting to be able to form a
mature relationship with the opposite sex since our patient is now in a
relationship.
Developmental Task
Developmental Task
Formal Operational stage
Period IV Formal Operations
(11 years- adulthood)
The final stage of Piagets theory involves an increase in logic, the ability to use an
understanding of abstract ideas, at this point people become capable of seeing
multiple potential solutions to problems and think more scientifically about the
world around them.
(psychology.com)
Theorist
Jean Piaget(1896-1980)
Cognitive Developmental Theory
Status
Positive Resolution
Patient is able to stay in school and he is a grade 7 student which means that's he
was able to face the problems in school. Also because of his cognitive ability that
is why he was promoted in grade 7.
Health Maintenance-Perception
Pattern
Health Maintenance-Perception
Pattern
Before hospitalization: Patient
ABC does not smoke or drink
alcoholic drinks. He has no allergies. During Hospitalization:
He does Basketball as his exercise
Patient does not smoke or
and has a good perception of health
take alcoholic drinks. He has
when he has cough usually takes
no allergies. He can't do any
the natural way of taking pure
Kalamansi juice but sometimes if
exercise since he is on bed.
cannot be controlled by the natural
He takes many prescribed
way patient takes over the counter
medications.
cough medications.
Nutritional-Metabolic Pattern
Before hospitalization: Patient
Elimination Pattern
Before hospitalization:
During hospitalization:
Before
hospitalization:Patient is
able to do self-care daily
activities independently
but depends on her
mother for the cooking.
Our patient is a basketball
player and this serves as
his exercise.
During hospitalization:
Patient as we have
observed during day is
always asleep and wakes
up only when we do
wound cleaning , vital
signs taking and giving of
medication. According to
his mother the patient
sleeps more comfortably
at night.
Before hospitalization:
During hospitalization:
Sexuality- Reproductive
Pattern:
During hospitalization:
Before hospitalization:
History of Present
Illness
Few hours prior to admission patient was with
Physical Assessment
Physical Assessment
Physical Assessment
Physical Assessment
Physical Assessment
Physical Assessment
Physical Assessment
Physical Assessment
Pathophysiology
DIAGNOSTIC TEST/LABORATORY
TEST
Complete Blood Count
Purpose of the Test
Normal
RBC: 4.5-5.4
Acomplete bloodcount HTC: 0.38-0.47
(CBC) gives important
HGB: 120-160
information about the
WBC: 5.0-10
kinds and numbers of
Differential Count
cells in the blood,
Lypmhocytes: 25-40
especially
Monocyets: 2-8
red blood cells,
Eosinophils: 1-4
white blood cells, and Basophils: 0-1
platelets. A CBC helps
Segmenters: 54-75
your doctor check any
Morphology Platelet
symptoms, such as
Count: 150-450
weakness,fatigue, or
MCV: 81.0-99.0
bruising, you may have. MCH: 27-31
A CBC also helps him or MCHC: 32-36
her diagnose
conditions, such as
anemia, infection, and
many other disorders.
(webmd.com
Results
(10/23/15):(10/20/15)
HGB: 79: 21 (Low)
HTC: 0.23: 0.07 (Low)
RBC: 2.63: 0.79 (Low)
WBC: 16.0: 11.7 (High)
Segmeters: 0.88: 42
(Low)
Lymphocte: .12: 21
(Low)
Eosinophil: 100: .
01/100 (Low)
Platelet count: 173:
200
Chest X-Ray
Purpose of the Test
An X-ray is an imaging
test that uses small
amounts of radiation to
produce pictures of the
organs, tissues, and
bones of the body. When
focused on the chest, it
can help spot
abnormalities or diseases
of the airways, blood
vessels, bones, heart, and
lungs.
(healthline.com)
Normal
As mentioned earlier, the
image on chest X-ray film is
in shades of black and
white, similar to a negative
of a regular photograph.
The shadows on a chest Xray test depend on the
degree of absorbed
radiation by the particular
organ based on its
composition. Bony
structures absorb the most
radiation and appear white
on the film. Hollow
structures containing mostly
air, such thelungs normally
appear dark. In a normal
chest X-ray, the chest cavity
is outlined on each side by
the white bony structures
that represent the ribs of
the chest wall. On the top
portion of the chest is the
neck and the collar bones
(clavicles). On the bottom,
the chest cavity is bordered
by the diaphragm under
which is the abdominal
cavity. On either side of the
chest wall, the bones of the
shoulders and arms are
Results
Hazy densities seen on
left peripheral area
consider pulmonary
contusion v. edema
Heart is magnified in this
projection
Note of an ET
Note also of a left side
thoracotomy tube
Note of surgical staples
on left chest wall
Subcutaneous
emphysema on the left
chest wall.
Diaphragm and sinuses
intact
Normal
pH: 7.35-7.45
PCO2: 35-45
PO2: 80-100
HCO3: 22-26
O2 sat: 95-100%
Results
MEDICAL/SURGICAL
PROCEDURES
Results
Implication
Results
CTT inserted at 6th ICS
10/20
10/21 10+300+200
10/22- 10+100+100+150
10/23- 150+ 100
10/24- 50
10/25
10/26
10/27
10/28--
Implications
Pulmonary contusion is an injury to lung
parenchyma, leading to of edema and
blood collecting in alveolar spaces and
loss of normal lung structure & function.
(trauma.org)
Results
(The tube was used correctly for
feeding.
Implications
NGT feeding was done to patient ABC
since he is unable to eat because of the
presence of ET tube.
NG tubes can be used to aid in the
prevention of vomiting and aspiration
Blood Transfusion
Purpose of the Test
Results
Implication
Mechanical Ventilator
Results
Results
Implication
MEDICATIONS
5. TETANUS TOXOID (Tetanus Toxoid Adsorbed, Tetanus Toxoid For Booster Use
Only,TeAnatoxal Berna)
Drug classification: Bacterial vaccines
Indication: Primary immunization.Adsorbed formulation
Common side effect: mild fever, joint pain, muscle ache, nausea, pain, hives, swelling of
eyes, tiredness
Nursing responsibility
1. physical examination, auscultation of breath sound heard (there Ronchi) every 2-4 hours.
2. Clean the mouth and respiratory tracts of mucus with a secret and do section
3. When given to women of child bearing age, vaccines that contain tetanus toxoid (TT or
Td) not only protect women against tetanus, but also prevent neonatal tetanus in their
newborn infant
4. When vaccines containing tetanus toxiod stand for a long time, the vaccine separates
from the liquid and looks like fine sand at the bottom of the vial. Shake the vial to mix the
vaccine and liquid again before giving the vaccine TT/Td/DTP vaccines should never be
frozen. the "shake test " will determine if the vaccine has been damaged by freezing..
5. Monitor any signs of side effect
7. PARACETAMOL (Calpol)
Drug classification: Analgesics; Muscle Relaxants.
Indication: Relief mild-to-moderate pain; treatment of fever.
Common side effects: Rash, swelling, hypotension, liver and kidney
damage
Nursing responsibility:
1. Assess patients fever or pain: type of pain, location, intensity, duration,
temperature, and diaphoresis.
2. Assess allergic reactions: rash, urticaria; if these occur, drug may have to
be discontinued.
3. Teach patient to recognize signs of chronic overdose: bleeding, bruising
malaise, fever, sore throat.
4. Tell patient to notify prescriber for pain/ fever lasting for more than 3 days.
5. Assess patients drug history and calculate total daily dosage accordingly.
8. OMEPRAZOLE (Prilosec)
Drug classification: Gastric acid secretion inhibitor; Proton pump inhibitor
Indication: Treatment of gastric ulcers, GERD, pathological hypersecretorysyndroms;
maintenance therapy for healing duodenal ulcers and esophagitis, treatment of heartburn or
symptoms of gastroesophageal reflux.
Common side effects: abdominal pain, gas; nausea, vomiting, diarrhea, headache.
Nursing responsibility:
1. Administer drug before meals to ensure that the patient does not open, chew, or crush
capsules; They should be swallowed whole to ensure the therapeutic effectiveness of the drug.
2. Encourage patient to avoid alcohol, aspirin products, ibuprofen, and foods that may increase
gastric secretions during therapy.
3. Assess neurological status, including level of orientation, affect, and reflexes, to evaluate for
CNS effects of the drug.
4. Monitor the patient for diarrhea or constipation in order to institute an appropriate bowel
program as needed.
5. Be aware that long term use of medication may increase the risk of gastric carcinoma
Nursing responsibility:
1. Assess patient carefully for signs of hypervolemia such as bounding
pulse and shortness of breath.
2. Assess patient carefully for signs of hypervolemia such as bounding
pulse, and shortness of breath.
Nursing Process
Problem #1:Presence of
Intubation Set
Objective Cues: Presence of endotracheal tube, reduced LOC, tube
Problem #1:Presence of
Intubation Set
NOC: Aspiration Prevention
Short Term: After 30 minutes of nursing
Problem #1:Presence of
Intubation Set
Independent:
Monitored level of consciousness; monitored respiratory rate, depth, and effort. Noted any signs of
Problem #1:Presence of
Intubation Set
Dependent:
Administer Omeprazole 40 mg x OD, as ordered by the physician.
Problem 2: Difficulty of
Breathing (10/26/15)
Objective Cues: Use of accessory muscle, tachypneic, dyspneic,
irrational combative behavior, deep rapid breathing, anxiety, O2 of 9899% with mechanical ventilator; 74% without mechanical ventilator
Subjective Cues: Nahihirapanpotalagasiyanghuminga,
natatakotpoakominsankasinagwawalaposiya. as verbalized by the
patients mother.
Nursing Diagnosis: Ineffective Breathing Patternrelated to decreased
lung compliance
Rationale: Ineffective breathing patterns are considered a state in
which the rate, timing, and rhythm, or chest/abdominal wall excursion
during inspiration and expiration or both do not maintain optimum
ventilation for the individual. Breathing pattern changes may occur in
in a multitude of conditions; heart failure, airway obstruction, trauma
or surgery, respiratory infection, and anxiety to name a few.(Gulanick
& Myers, 2013)
Problem 2: Difficulty of
Breathing (10/26/15)
Nursing Diagnosis: Impaired gas exchange related to alveolar
hypoventilation
Rationale: By the process of diffusion, the exchange of oxygen and carbon
dioxide occurs in the alveolar-capillary membrane area. The relationship
between ventilation (airflow) and perfusion (blood flow) affects the efficiency
of the gas exchange. Normally a balance exists between ventilation and
perfusion; however, certain conditions can offset this balance, resulting in
impaired gas exchange.(Ralph & Taylor, 2010)
NOC: Respiratory Status: Ventilation
Short-team goal: After 1 hour of nursing intervention patient will be
ablemaintainan adequate O2 saturation rate of 95-100% with the assistance
of the mechanical ventilator.
Long-Term Goal:After 2 days of nursing intervention, patient will maintain a
normal range of O2 saturation (95-100%) with mechanical ventilator; a
decrease in respiratory rate from 36 bpm to 20 bpm and will not manifest any
signs of respiratory complications such as atelectasis and pneumonia.
NIC: Respiratory Monitoring
Problem 2: Difficulty of
Breathing (10/26/15)
Independent:
Monitored for changes in mental status, restlessness, anxiety, confusion or headache; Assessed
respiratory system, including rate, depth, effort, rhythm, use of accessory muscle, breath
sounds, presence of cough, and skin color.
Rationale: Changes in mental status may indicate impending or present hypoxia and
hypoxemia; Assessing the respiratory helps determine a baseline in order to evaluate response
to treatment; decreasing respiratory rate along with deterioration in other assessment
parameters may signal respiratory failure.
Assisted patient to semi-fowlers or fowlers position.
Rationale: Sitting upright allows the diaphragm to descend resulting in easier breathing and
improved gas exchange and it helps prevent ventilator-associated pneumonia (VAP).
Monitored results of arterial blood gases and O2 saturation.
Rationale: Provides information on measures levels of oxygen and carbon dioxide as well as
acid-base balance. Promotes intervention for deteriorating airway status. PaO2 alone does not
reflect tissue oxygenation; ventilation must be adequate to provide gas exchange.
Suctioned Patient every 2-4 hours and prn.
Rationale: Hyperoxygenate prior to and after suctioning. Removes mucus that may occlude
airways. O2 concentration drops tragically with suctioning procedures and leaves patient
compromised with an increase O2 consumption, hyperoxygention helps to minimize the drastic
decrease in O2 concentration and to keep patient adequately oxygenated and tissues perfused.
Problem 2: Difficulty of
Breathing (10/26/15)
Dependent:
Administered Salbutamol, 1 tab q8 as ordered by physician.
tachypneic, dyspneic
Subjective Cues:
Dyanyatayungmasakitkasidyanpalagiangtinuturoniya. As
verbalized by the mother.
Nursing Diagnosis: Acute Pain related to Chest Thoracotomy
Tube Insertion
Rationale:A large buildup of fluid or air in the chest can make
it difficult to breathe. Removing some of the fluid or air may
decrease discomfort and make it easier to breathe but pain
occurs when chest tube is inserted. It is also said to be a very
painful procedure, pain medications should be given in
patients with chest thoracotomy tube. (American Thoracic
Society, 2013)
interventions.
Rationale: All patients with chest trauma will need some type of pain medication. Pain management is
easiest if the pain is not allowed to peak but is constantly controlled. If one medication or
complementary technique is not effective, other interventions will need to be implemented.
Eliminate additional stressors or sources of discomfort whenever possible.
Rationale: Patients may experience an exaggeration in pain or a decreased ability to tolerate painful
stimuli when environmental, intrapersonal, or intrapsychic stressors are present.
Instructed client to report location, intensity and quality when experiencing pain.
Rationale: The intensity of pain and discomfort should be assessed and documented after any known
pain-producing procedure, with each new report of pain, and at regular intervals
Assessed vital signs, and any signs of increase blood pressure, tachycardia and increased respiration.
Rationale: Changes in vital signs may indicate acute pain and discomfort
Maintained bed rest with position of comfort; nurse to stay with patient during pain.
Rationale: Reduces oxygen consumption, and demand; alleviates fear and provides caring atmosphere.
Instruct patient/family in medication effects, side effects, contraindications, and symptoms to report.
Rationale: Promotes knowledge and compliance with therapeutic regimen. Alleviates fear of unknown.
physician.
Rationale: To relieve moderate to moderatelysevere pain.
Evaluation:
Short Term: Goal partially met. Patient manifested a
decrease in pain as evidenced by a more relax facial
expression. He did not manifest a decrease in respiratory
rate (from 36 bpm to 20 bpm) and a decrease in blood
pressure (from 130/100 to 120/80).
Long Term:Goal Met. Within the shift, the patient was able
to control the pain through medications as evidenced by a
more wind down facial expression.
communication.
Rationale: Chest-Trauma can result in an acute life-threatening injury that will produce high levels of
anxiety as well as in significant others.
Reduced the patients or significant others anxiety by explaining all procedures and treatment.
Rationale: Keep explanation basic. Information helps allay anxiety. Patients who are anxious may not
be able to comprehend anything more than simple, clear, brief instructions.
Assessed coping factors.
Rationale: Anxiety and ways of decrease perceived anxiety are highly individualized. Interventions
are most effective when they are consistent with patients established coping pattern.
Identified and reduced as many stressors as possible.
Rationale: This may allow patient identify anxious behaviors and discover the source of anxiety.
Maintained a confident, assured manner.
Rationale: Assure patient and significant others of close, continuous monitoring, that will ensure
prompt interventions. Presence of trusted person may help the patient feel less threatened. The
staffs anxiety may be easily perceived by the patient. The patients feeling of stability increases
calm, nonthreatening atmosphere.
Provided support and encouragement to family members and assist them in dealing with their own
fears/concerns.
Rationale: Familys anxiety may be communicated to the patient and result in increased anxiety
levels.
physician.
Rationale: To relieve anxiety.
Evaluation
Short Term: Goal Met. After 3 hours of nursing
intervention, patient demonstrated a reduced level of
anxiety as evidenced by a more relax facial expression.
Long Term: Goal Met. After the shift, the patient
showed no episodes of anxiety as evidenced by not
being afraid or participating when taking vital signs and
cleaning wounds.