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    Pain

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    bienne carpio
    Kenneth is a single Catholic male who presented with skin trauma to his right lower abdomen area. He reported falling and noticing a lot of blood coming from the wound. On examination, he displayed guarding of the right lower quadrant and a facial grimace when the wound was touched. His pain level was 6/10. The goal is for the wound to stop bleeding within 10 minutes and for him to be able to walk with little effort. Long term, he should be able to walk normally and the skin trauma should close within a week. The nursing interventions include cleaning and disinfecting the wound, moving him every two hours, educating him on proper wound care, and assessing his pain level.

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    Pain

    Uploaded by

    bienne carpio
    44 views1 page
    Kenneth is a single Catholic male who presented with skin trauma to his right lower abdomen area. He reported falling and noticing a lot of blood coming from the wound. On examination, he displayed guarding of the right lower quadrant and a facial grimace when the wound was touched. His pain level was 6/10. The goal is for the wound to stop bleeding within 10 minutes and for him to be able to walk with little effort. Long term, he should be able to walk normally and the skin trauma should close within a week. The nursing interventions include cleaning and disinfecting the wound, moving him every two hours, educating him on proper wound care, and assessing his pain level.

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    pain

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    Kenneth is a single Catholic male who presented with skin trauma to his right lower abdomen area. He reported falling and noticing a lot of blood coming from the wound. On examination, he displayed guarding of the right lower quadrant and a facial grimace when the wound was touched. His pain level was 6/10. The goal is for the wound to stop bleeding within 10 minutes and for him to be able to walk with little effort. Long term, he should be able to walk normally and the skin trauma should close within a week. The nursing interventions include cleaning and disinfecting the wound, moving him every two hours, educating him on proper wound care, and assessing his pain level.

    Copyright:

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

    Pain

    Uploaded by

    bienne carpio
    Kenneth is a single Catholic male who presented with skin trauma to his right lower abdomen area. He reported falling and noticing a lot of blood coming from the wound. On examination, he displayed guarding of the right lower quadrant and a facial grimace when the wound was touched. His pain level was 6/10. The goal is for the wound to stop bleeding within 10 minutes and for him to be able to walk with little effort. Long term, he should be able to walk normally and the skin trauma should close within a week. The nursing interventions include cleaning and disinfecting the wound, moving him every two hours, educating him on proper wound care, and assessing his pain level.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    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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