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    Fundalec 2

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    bienne carpio
    Kenneth is a single Catholic male who experienced skin trauma in the form of a cut on his right lower abdomen. His subjective complaint was that he thought he just passed gas but saw a lot of blood when he touched the area. Objectively, he exhibited guarding of the right lower quadrant, a facial grimace when the wound was touched, and difficulty walking. The nursing diagnosis is impaired skin integrity related to the skin trauma. Short term goals are for the bleeding to stop within 10 minutes and for him to be able to walk with little effort. Long term goals are for him to walk normally and for the skin trauma to close within a week. Nursing interventions include cleaning and disinfecting the wound, moving the patient

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    Fundalec 2

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    bienne carpio
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    Kenneth is a single Catholic male who experienced skin trauma in the form of a cut on his right lower abdomen. His subjective complaint was that he thought he just passed gas but saw a lot of blood when he touched the area. Objectively, he exhibited guarding of the right lower quadrant, a facial grimace when the wound was touched, and difficulty walking. The nursing diagnosis is impaired skin integrity related to the skin trauma. Short term goals are for the bleeding to stop within 10 minutes and for him to be able to walk with little effort. Long term goals are for him to walk normally and for the skin trauma to close within a week. Nursing interventions include cleaning and disinfecting the wound, moving the patient

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    Kenneth is a single Catholic male who experienced skin trauma in the form of a cut on his right lower abdomen. His subjective complaint was that he thought he just passed gas but saw a lot of blood when he touched the area. Objectively, he exhibited guarding of the right lower quadrant, a facial grimace when the wound was touched, and difficulty walking. The nursing diagnosis is impaired skin integrity related to the skin trauma. Short term goals are for the bleeding to stop within 10 minutes and for him to be able to walk with little effort. Long term goals are for him to walk normally and for the skin trauma to close within a week. Nursing interventions include cleaning and disinfecting the wound, moving the patient

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views1 page

    Fundalec 2

    Uploaded by

    bienne carpio
    Kenneth is a single Catholic male who experienced skin trauma in the form of a cut on his right lower abdomen. His subjective complaint was that he thought he just passed gas but saw a lot of blood when he touched the area. Objectively, he exhibited guarding of the right lower quadrant, a facial grimace when the wound was touched, and difficulty walking. The nursing diagnosis is impaired skin integrity related to the skin trauma. Short term goals are for the bleeding to stop within 10 minutes and for him to be able to walk with little effort. Long term goals are for him to walk normally and for the skin trauma to close within a week. Nursing interventions include cleaning and disinfecting the wound, moving the patient

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    CARPIO, Bienne Zyrus Earl T.

    BSN 1-NAZ
    Client name: Kenneth Religion: Catholic
    Gender: Male Civil Status: Single
    PROBLEM/ NURSING EXPLANATION OF THE GOAL/OUTCOME NURSING RATIONALE EVALUATION
    DIAGNOSIS PROBLEM INTERVENTIONS
    Subjective: Skin trauma is serious and Long term: Dx: Moving patient every two
    “Akala ko nagas-gas lang ako altering physical injury Patient should be able to walk Administer supplemental hours could help the patient’s
    nung natumba ako pero nung experienced by the skin or normally and skin trauma need in cleaning or blood flow normally.
    nahawakan ko na ang dami multiple layers of epithelial should close within a week. disinfecting the wound. Move Proper wound cleaning is an
    nang dugong lumalabas” as tissues. This can be in the patient every two hours effective way for the client’s
    stated by the patient form of cuts, burns, Short term goal: wound to heal faster and is
    sickness or other injury. Within the first 10 minutes Educative: also a way to prevent
    Objective: patients wound should stop Advice patient not to the complications/infection of the
     Guarding position on bleeding and patient should wound and clean it regularly wound.
    the right lower be able to walk with little in order to prevent infection. Assessing client’s pain can
    quadrant of the effort. Teach patient proper wound help us determine on what
    abdomen. cleaning. type of care the nurse would
     Facial grimace when apply to the patient.
    wound is touched Therapeutic:
     Patient has a hard Assess client’s pain using
    time walking. pain scale measure.
     Patients pain is 6/10 Encourage patient to be more
    careful when running around.
    Nursing diagnosis:

    Impaired skin integrity


    related to skin trauma as
    manifested by bleeding in
    the right lower quadrant of
    the abdomen, facial grimace
    and guarding position of the
    patient.

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