Pineda, Aira Mae Jasmin D.

BSN 3-Y1-10

CASE SCENARIO in MEDICAL SURGICAL NURSING

CHEST INJURY

Pre-Hospital Data

Marlin Ponce, a 19 years old student at OLFU, was going to her school to pay her dues at the
accounting office, when suddenly a victim of stabbing while outside the campus. This all began when a
stranger approached her and asked her for some money which occurred immediately after this man saw
her. What started out as a verbal argument and she was refusing to give this stranger her money,
eventually resulted in a physical violence. Marlin sustained a single stab wound to the left chest in the
mid axillary line, just below the level of the nipple. She was transported to emergency department at the
nearby hospital NEDHI by the bystanders who witnessed the incidence. He was noted to be awake and
alert throughout the entire transport, but in an agony of the pain she was experiencing from the stab
wounds.

After several hours of observations, Marlin, at this time began complaining of a new subscapular pain, or
pain between the shoulder blades. The doctor was alarmed for the following reasons:

Patients with diaphragmatic injuries and irritation from the blood frequently exhibit referred pain in this
distribution. If the knife wound had projected inferiorly penetrating the diaphragm, there was also a high
likelihood of intra-abdominal injuries. Therefore, it was decided that the patient required surgical
exploration, and the patient was taken to the operating room.

Emergency Room

Assessment:

The patient complained of some pain in her left chest and shortness of breath while she is moving from
the stretcher onto the examination table.

The nurse placed cardiac monitors, blood pressure-cuff and oxygen saturation probe on her. Vital signs
result as follows:

Heart rate- 8am 91b/min, 84b/min,72b/min, 101b/min, 64b/min, 92b/min, 71b/min, 89b/min, 62b/min

Blood Pressure- 140/90, 130/70, 120/80, 140/90, 130/70, 120/80, 140/90, 130/70, 120/80, 140/90

Respiratory rate – 26, 18, 30, 21. 18, 24, 35, 24, 20, 16, 35, 23, 30, 16, 18, 20

Temperature- 37.2 ‘C, 38.1, 36. 3, 37.2 ‘C, 38.2, 36. 5, 37.5 ‘C, 36.1, 36. 3, 37.2 ‘C, 36.1, 37. 3

I and O monitoring

9am total : I = NPO, IVF =160, urine =800 cc, BM =0, CTT out 200cc
1pm: Oral =NPO, IVF =160, urine = 760 cc, BM=1x, CTT output =300 cc

5pm: oral 120 cc of water , IVF =160,urine =700 cc, BM =0, CTT output =500 cc

9pm: oral 200 cc of milk , IVF=160 cc, urine =600 cc, BM =0 , CTT output=800cc

1am: oral = 100cc of water , IVF =160cc , urine =500 cc, BM=0 , CTT output = 550 cc

IVF: PNSS 1 L x 24, (drop factor 20) inserted @ cephalic vien Right hand , using 18 IVcatheter, started @
6am

Past Medical/Surgical History: Allergic Rhinitis, Asthma

Family History: Father is diabetic, Mother has hypertension

Medications: Medication for pain and antibiotic ( make your own order for pain and antibiotic) make an
drug study. Inhalers as needed

Allergy: Pain Medications such as IBUFROPEN (Alaxan, Gardan etc.)

Chest X-ray: Left sided hemo-pneumothorax

An upright CXR was done. Marlin needs to be sat up because she had an isolated penetrating injury to
the chest, and the mechanism of injury did not warrant spinal precautions. Due to this isolated nature of
her injury a pelvis and lateral C-spine films were unfortunately not obtained.

Medication for pain and antibiotic (decide and make your own order for pain and antibiotic) make a drug
study.

Initial Survey:

Airway - There is patent airway as demonstrated by her ability to complain or talk.

Breathing -There is decreased breath sounds at the left base.

Oxygen mask with 100% FiO2 was placed; & an oxygen saturation of 98 % was obtained

Circulation – There is no active external bleeding observed

Exposure –The patient’s clothes were cut off and removed to examine for other injuries

Secondary Survey:

EENT: (-) lacerations, (-) hematomas, (-) fractures palpated

Neck: midline trachea, (-) JVD, (-) crepitus

Chest: clear on right, single stab wound to the left chest in the mid-axillary line in the 4th intercostal
space, no crepitus, no bleeding, decreased breath sounds at the left base

Cardiac: Normal RR, normal S1 and S2

Abdomen: soft, non-tender, non-distended, with presence of abdominal sounds

Extremities: warm to touch, (+) distal pulses

Neuro: GCS 15, (-) focal deficits, awake, GCS 13, GCS 14, GCS 13, GCS 14, GCS 15, GCS 15

Laboratory and other pertinent studies

Blood Work Ordered:

Coagulation panel

Complete blood count (CBC)

Arterial blood gas

Toxicology screen

QUESTIONS:

1. What is the best nursing diagnosis for Marlin’s case?

Acute Pain related to chest stab wound

2. As the student nurse assigned to Marlin, how will you manage her pain?
As the student nurse responsible for Marlin's care, my priority is managing her pain effectively. I
will begin with a comprehensive pain assessment, considering the pain's characteristics and
intensity. Administering prescribed pain medications. I will complement this with non-
pharmacological techniques like relaxation exercises. Educating Marlin about her pain relief plan
and advocating for her comfort will be integral in ensuring her well-being during her recovery.

3. What are the expected medications to be given to Marlin to alleviate her pain? Create at least 3
drug studies.

MEDICA MECHA INDICATI CONTRAINDI DRUG TO ADVERSE NURSING

TION NISM ONS CATIONS DRUG EFFECTS CONSIDERATIO
OF INTERACTI N/PATIENT
ACTION ON TEACHING

Generic Binds  Adjunc  Patients’ Amiodaron CNS:  Caution

Name: with t to intolerant e: may asthenia, patient or
opioid genera to drug cause clouded caregiver
Fentanyl receptor l  Transderm hypotension sensorium, of taking
Citrate s in the anesth al form is , confusion, an opioid
CNS, esia contraindic bradycardia euphoria, with a
Brand
altering  Adjunc ated to , and sedation, benzodiaz
Name:
percepti t to patients decreased somnolenc epine,
Fentanyl on of region with acute cardiac e, seizures, CNS
and al or severe output. anxiety, depressan
Drug emotion anesth bronchial Monitor depression t, or
Class: al esia asthma, patients s, alcohol to
respons  To known, or closely. dizziness, seek
Opioid e to induce suspected Benzodiaz hallucinatio medical
Analgesi pain. and paralytic epines, ns, attention
cs maintai ileus, and CNS headache, for
n GI depressant nervousnes dizziness,
DOSAG anesth obstruction s: May s. light-
E: esia . cause slow headedne
 Postop  Fentora is or difficult CV: ss,
50 to 100 arrhythmia
erative contraindic breathing, extreme
mcg s, chest
pain, ated to sedation, sleepiness
restles patients and death. pain, HTN, , slowed
FREQUE
sness, with brain Avoid using hypotensio or difficult
NCY:
tachyp tumors, it together. n. breathing,
every 1-2 nea, COPD, If using or
DVT, PE,
hrs. and decreased together is unrespons
EENT:
emerg respiratory necessary, iveness.
ROUTE: pharyngitis,
ence reserve, limit dosage  When a
IM dry eyes,
deliriu potentially and drug is
swelling,
m compromis duration of used for
strabismus,
 Preope ed each drug pain
ptosis,
rative respiration to the control,
epistaxis,
medica s, hepatic minimum instruct
nasal
tion or renal necessary the patient
discomfort,
 To disease, or for desired to request
rhinorrhea,
manag cardiac effect. the drug
nasal
e bradyarrhyt CY3A4 before
congestion,
persist hmias. inducers pain
postnasal
ent,  Use with (carbamaz becomes
drip, rhinitis
moder caution in epine, intense.
(intranasal)
ate to elderly or phenytoin,  Teach
GI:
severe deliberated rifampin): patients
constipatio
chronic patients. may that
n,
pain in  Opioids decrease naloxone
abdominal
opioid- can use efficacy or is
pain,
toleran sleep- precipitate prescribed
anorexia,
t related a in
diarrhea,
patient breathing withdrawal conjunctio
dyspepsia,
s who disorders, syndrome n with the
dry mouth,
require including in patients opioid
ileus,
around central with when
nausea,
-the- sleep physical beginning
vomiting.
clock apnea dependenc and
analge (CSA) and e on GU: urine renewing
sics for sleep fentanyl. If retention treatment
an related CYP3A4 Musculosk as a
extend hypoxemia. inducer is eletal: preventive
ed time Opioid use discontinue skeletal measure
 To increases d, fentanyl muscle to reduce
manag risk of CSA level may rigidity opioid
increase overdose
 e in a dose and cause (dose- and death
breakt dependent fentanyl- related)  Tell
hrough fashion. In related Respirator homecare
cancer patients adverse y: apnea, patients to
pain in who reactions. hypoventila avoid
patient present CYP3A4 tion, drinking
s with CSA, Inhibitors respiratory alcohol or
already consider (erythromyc depression, taking
receivi decreasing in, dyspnea, CNS-type
ng and opioid ketoconazol cough, drugs,
tolerati dosage e, ritonavir): URI, unless
ng using best may bronchitis. specificall
opioid. practices increase Skin: y
 Switchi for opioid fentanyl diaphoresis prescribed
ng taper. level and , pruritus, by a
from increase erythema practitione
Actiq potentially at r, because
to fatal application additive
Fentor respiratory site effects
a to depression. (transderm can occur.
manag Use al)
e together
breakt cautiously Other:
hrough and monitor physical
cancer patients dependenc
pain in closely. e
opioid- Diazepam:
toleran may cause
t CV
patient depression
s. when given
with doses
of fentanyl.
Monitor
patient
closely
droperidol:
may cause
hypotension
and
decrease
pulmonary
arterial
pressure.
Use
together
cautiously.
 General
Anesthetic
s,
hypnotics,
and other
opioid
analgesics,
sedatives,
TCAs: may
cause
additive
effects. Use
together
cautiously.
Consider
dosage
reduction of
one or both
drugs if
adverse
effects
occur

MEDICA MECHA INDICATIO CONTRAINDI DRUG TO ADVERSE NURSING

TION NISM NS CATIONS DRUG EFFECTS CONSIDERATIO
OF INTERACT N/PATIENT
ACTION ION TEACHING

Generic Binds  Mo  Patient Alvimopan CNS:  Caution

Name: with der s’ : may dizziness, patient or
Morphine opioid ate hypert enhance drowsiness caregiver
hydrochl receptor to ensive adverse/ , of patient
oride s in the Sev to toxic effects headache, of taking
CNS, ere drugs of euphoria, an opioid
Brand altering Pan and in alvimopan. light- with a
Name: percepti  Mo those Alvimopan headednes benzodiaz
Doloral on of der with is s, epine,
and ate conditi contraindic nightmares CNS
Drug
emotion to ons ated to , sedatives, depressa
Class:
al sev that patients somnolenc nt, or
Opioid
respons ere would taking e, seizures, alcohol to
Analgesi
e to pain preclu therapeutic depression, seek
cs
pain. req de IV doses of hallucinatio medical
DOSAG
uirin admini opioids for ns, attention
E: 0.1 to
g stratio more than nervousnes for
0.2
cont n of 7 s, physical dizziness
mg/kg
inuo opioids consecutive dependenc  Explain
FREQUE
NCY: us, (acute days e, syncope, assessme
every 4 aro bronch immediatel anxiety nt and
hours und ial y before monitorin
p.r.n - asthm alvimopan CV: g process
ROUTE: the- a, initiation. bradycardi to patient
IV cloc upper Consider a, cardiac and
k airway therapy arrest, family.
oral obstru modificatio shock, Instruct
opio ction) n. HTN, them to
id  Patien Benzodiaz hypotensio immediat
ts with epines, n, ely report
GI CNS tachycardia difficulty
obstru depressan , of
ction ts: may palpitation, breathing
 Use cause slow s or other
with or difficult peripheral S/S of a
caution breathing, circulatory potential
in sedation, collapse, adverse
elderly and death. peripheral opioid
or Avoid using edema, related
debilita it together. chest pain reaction
ted If using it  Warn
EENT:
patient together is patient
miosis,
s in necessary, that
blurred
those limit morphine
vision GI:
with dosage and can cause
constipatio
head duration of constipati
n, nausea,
injury, each drug on
vomiting,
increas to the  When
anorexia,
ed minimum drugs are
biliary tract
ICP, necessary used after
spasms,
seizure for desired surgery,
dry mouth,
s, effect. encourag
ileus,
COPD, e the
General flatulence,
prostat patient to
Anesthetic abdominal
ic turn,
s, pain
hyperp cough,
lasia, hypnotics, deep
GU: urine
severe MAO breath,
retention
hepatic inhibitors, and use
Hematologi
or other an
c:
renal opioid incentive
thrombocyt
diseas analgesics spiromete
openia,
e, , TCAs: r to
anemia,
acute may cause prevent
leukopenia
abdom respiratory lung
Respiratory
inal depression, problems.
: apnea,
hypotensio
conditi respiratory  Warn
ons, n, profound
 hypoth sedation, or arrest, patient
yroidis coma. Use respiratory not to
m, together depression crush,
addiso with Skin: break, or
n caution, diaphoresis chew
diseas reduce , edema, extended-
e, and morphine pruritus, release
urethra dose, and skin forms.
l monitor flushing,
strictur patient pain,
e response. injection
 Use in P2Y12
caution Inhibitors: n site
with may
patient decrease
s with absorption
circulat and peak
ory concentrati
shock, on of oral
biliary P2Y12
tract inhibitors
diseas when used
e, CNS with IV
depres morphine
sion, sulfate and
toxic delay onset
psycho of
sis, antiplatelet
acute effect.
alcohol Consider
ism, use of a
deliriu parenteral
m, antiplatelet
tremen agent in the
s, and setting of
seizure ACS
disord requiring
ers coadministr
ation of IV
morphine.

MEDICA MECHA INDICATI CONTRAINDI DRUG TO ADVERSE NURSING

TION NISM ONS CATIONS DRUG EFFECTS CONSIDERATIO
OF INTERACTI N/PATIENT
ACTION ON TEACHING

Generic May  RA,  Patients’ Anticoagul CNS:  Check renal

Name: inhibit osteoa hypertensi ants dizziness, and hepatic
Ibuprofe prostagl rthritis, ve to drug (Warfarin): headache, function
n andin arthriti and those may nervousnes periodically in
synthesi s with increase risk s CV: patients on
Brand s, to  Mild angioedem of serious GI edema, long term
Name: produce to a, bleeding. fluid therapy. Stop
Advil anti- moder syndrome Use with retention drug if
inflamm ate of nasal extreme EENT: abnormalities
Drug
atory, pain; polyps, or caution if tinnitus occur and
Class:
analgesi moder bronchosp concomitant notify
NSAIDs GI:
c, and ate to astic use cannot prescriber.
antipyret severe reaction to be avoided. abdominal  Monitor BP
DOSAG
ic pain aspirin or Monitor pain, because drug
E: 200 to
effects. as an other patients bloating, can lead to
400 mg
adjunc NSAIDs. closely. constipatio new onset of
FREQUE
t to  Contraindic Antihyperte n, HTN or
NCY:
opioid ated for nsives, decreased worsening of
every 4-6
analge treatment Furosemide appetite, preexisting
hrs p.r.n
sics; of , Thiazide diarrhea, HTN which
ROUTE: fever perioperati Diuretics: dyspepsia, may
PO reducti ve pain may flatulence, contribute to
on in after decrease heartburn, the increased
childre CABG the nausea, incidence of
n surgery effectivenes vomiting CV events.
 mild  NSAIDs s of diuretics  Because of
GU: acute
to can or their
renal
moder increase antihyperten antipyretic
failure,
ate risk of sives. and anti-
azotemia,
pain, heart inflammatory
Aspirin: cystitis,
fever attack or actions,
May negate hematuria,
 Relief stroke in
Hematolog
NSAIDs may
patients the mask the
of ic:
with or antiplatelet signs and
signs agranulocyt
without effect of low- symptoms of
and osis,
heart dose aspirin infection.
sympt aplastic
therapy.
oms of disease or
anemia,  Blurred or
risk factors Advise the
juvenil leukopenia, diminished
for heart patient on
e neutropeni vision and
disease. the
arthriti a, changes in
appropriate
s  Use pancytopen color in vision
spacing of
 Migrai cautiously ia, may occur
doses.
ne in elderly thrombocyt  Full anti-
Aspirin,
 Clinica and openia, inflammatory
corticoster
lly patients anemia, effects may
oids: May
patent with GI prolonged take 1 or 2
cause
ductus disorders, bleeding weeks to
adverse GI
arterio history of time develop
reactions.
sus peptic Metabolic: Patient
Avoid using
 (PDA) ulcer it together. hypokalemi Teaching:
(Ibupro disease, Bisphosph a,  Teach patient
fen cardiac onates: hypoglyce to take with
lysine) decompen may mia meals or milk
sation, increase risk to reduce
HTN, of gastric Skin: adverse GI
asthma, or ulceration. pruritus, reactions.
intrinsic Monitor injection-  Caution
coagulatio patient for site patient that
n defects. signs of irritation use with
 May gastric aspirin,
increase irritation or anticoagulants
risk for bleeding. , alcohol, or
aseptic Cyclospori corticosteroids
meningitis, ne: may may increase
with fever increase risk of GI
and coma, nephrotoxicit adverse
particularly y of both reactions.
in patients drugs. Avoid  Teach patient
with SLE using it to watch for
and related together. and
connective Digoxin, immediately
tissue Lithium: report signs
disease may and
increase symptoms of
levels of GI bleeding
these drugs. including
Monitor blood in vomit,
patient for urine, or stool;
toxicity. coffee-brown
Methotrexat vomit and
e: may black-tarry
decrease stool.
methotrexat  Advise patient
e clearance to wear
and sunscreen to
increase avoid
toxicity hypersensitivit
y to sunlight

4. What is the purpose of the Arterial blood gas analysis ordered by Marlin’s attending physician? How
will you prepare Marlin for this test?

The attending physician has ordered an arterial blood gas (ABG) analysis for Marlin, and this test is
essential given her chest stab wound. Its primary purpose is to evaluate her respiratory status, acid-base
equilibrium, and arterial oxygenation levels. It provides crucial insights into her lung function and oxygen
levels.
In preparation for the ABG test, I will initiate the process by clearly explaining the procedure to Marlin,
ensuring her understanding and consent. Before proceeding, I'll clarify the purpose of the consent form
and inquire about allergies and potential medication interactions. Ensuring Marlin's comfort, I'll position
her appropriately, and finally, I will meticulously document all gathered information to facilitate a well-
documented and safe procedure.

5. What are the significance of the different blood (Coagulation panel, CBC etc.) work ordered by the
doctor?

The blood work ordered, which includes the coagulation panel, complete blood count (CBC), arterial
blood gas (ABG), and toxicology screen, yield critical information for assessing Marlin's health following
the chest stab wound.

The coagulation panel, which assesses blood clotting, plays a vital role in identifying bleeding disorders or
thrombotic risks arising from the injury. The CBC, featuring elements such as hemoglobin and white blood
cell count, aids in identifying potential anemia due to blood loss, detecting signs of infection or
inflammation, and evaluating platelet counts crucial for clotting. ABG analysis assesses her respiratory
condition and oxygen levels, guiding interventions for impaired lung function due to the chest injury.
Lastly, the toxicology screen aims to uncover any substances that may have influenced her injury or
impacted her overall health.

Together, these blood tests provide a comprehensive evaluation, guiding precise diagnosis and
personalized treatment strategies to enhance her well-being.

6. Why is ABG is being ordered? State your reasons.

Based on the provided case study, Marlin sustained a stab wound to the chest. An arterial blood gas
(ABG) analysis has been ordered to assess her respiratory status, detect hypoxemia, evaluate acid-base
balance, guide treatment decisions, and monitor her response to interventions.

Given the potential impact of the chest injury on lung function and gas exchange, ABG results provide
crucial information about oxygen and carbon dioxide levels in the blood. This information assists
healthcare providers in determining the necessity for supplemental oxygen therapy, assessing the extent
of respiratory impairment, and making informed decisions to optimize Marlin's respiratory care and overall
health.

7. Which of these 2 diagnostic procedures does apply to Marlin’s case? Give your reasons.

A) Open laparotomy B) Diagnostic Laparoscopy

Based on the information given about Marlin’s case, I’ll choose Open laparotomy instead of Diagnostic
laparoscopy since she’s experiencing a chest stab wound and subsequent subscapular pain.

The emergence of subscapular pain is particularly significant due to its possible connection with
diaphragmatic injuries. If the knife wound had extended inferiorly, potentially penetrating the diaphragm, it
could lead to irritation and damage within the abdominal cavity. Consequently, opting for an open
laparotomy becomes pertinent as it allows for comprehensive exploration of both the chest and abdominal
areas. This surgical approach is crucial for the assessment and management of potential intra-abdominal
injuries, which may not be immediately evident but could have occurred as a result of the same traumatic
incident.
Selecting an open laparotomy ensures that Marlin's medical care is tailored to her specific condition,
offering a thorough evaluation and intervention as required.

8. If the knife wound had projected inferiorly penetrate the diaphragm, there is also a likelihood of intra-
abdominal injuries. Make 3 NCPs on this. Impaired Breathing pattern – ABG result with oxygenation, Pain
with pain scale of 8/10 on the operative site, Impaired physical mobility due to presence of CTT 1 way
bottle.

Impaired Breathing pattern – ABG result with oxygenation

ASSESSMENT DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATIO

S N N

Subjective Ineffective After 5 hours 1. Assess the 1. Regularly After 5 hours

Data: Airway of nursing respiratory checking the of nursing
Clearance intervention, status. patient's intervention,
Stab wound to related to the patient 2. Oxygen breathing the patient
the left chest decreased will be able Therapy. helps detect was able to:
with left-sided breath to: 3. Monitor VS any changes
hemo- sounds as and cardiac early, - Understa
pneumothorax. evidenced - Understa rhythm. ensuring nd the
by nd the 4. Position the timely importanc
Objective Data: importanc e of deep
shortness patient in a intervention
of breath e of deep comfortable for chest breathing
Vital Signs:
and breathing position. stab wound- and
PR: 91bpm to fluctuating and 5. Administer related coughing
101bpm respiratory coughing the issues like exercises
rate. exercises prescribed pneumothor in
BP: 120/80 to in pain ax. maintaini
140/90 maintaini medication 2. Administerin ng lung
ng lung prescribed. g extra function.
RR: 16-35 function. - Maintain
6. Monitor for oxygen
- Maintain complication maintains a
TEMP: 36.1°C to
a s. adequate respirator
38.2°C
respirator oxygen y rate
Assessment of y rate levels, between
physical between preventing 16-20
findings: 16-20 hypoxia due breaths
breaths to potential per
 Decreas per lung function minute.
ed minute. impairment.
breath - Achieve Achieve and
3. Continuous
sounds and maintain
monitoring of
at the maintain oxygen
vital signs
left oxygen saturation
and cardiac
base. saturation above 95%.
rhythm
above ensures
 Shortnes 95%. prompt
s of identification
breath. of cardiac
 Stab complication
wound s near the
to the heart.
left chest 4. Proper
in the positioning
mid- enhances
axillary lung
line in expansion
the 4th and patient
intercost comfort,
al space. improving
respiratory
function and
preventing
atelectasis.
5. Effective
pain
management
encourages
participation
in crucial
activities like
deep
breathing
and
coughing,
aiding lung
function
recovery.
6. Regular
checks for
complication
s, such as
infection or
tension
pneumothor
ax, facilitate
early
intervention,
preventing
further
respiratory
and overall
health
issues.
Pain with pain scale of 8/10 on the operative site

ASSESSMENT DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATIO

S N N

Subjective Data: Impaired After 4 hours 1. Assess 1. Regular After 4 hours

Gas of nursing pain pain of nursing
She experiences Exchange intervention, characteris assessme intervention,
severe pain in her related to the patient will tics nts help in the patient will
left chest and left hemo- be able to: evaluating be able to:
subscapular area. pneumothor 2. Administer the
ax and 1. Report a prescribed effectiven 3. Report a
Objective Data: pain scale pain pain scale
decreased ess of
lung rating of medication pain rating of
Vital Signs:
function. 3/10 or as ordered managem 3/10 or
PR: 91bpm to lower. ent lower.
3. Provide
101bpm interventio
2. Demonstr comfort 4. Demonstr
ns.
BP: 120/80 to ate measures ate
140/90 effective 2. Administer effective
pain 4. Educate pain
ing
RR: 16-35 managem the patient managem
prescribed
ent about pain ent
pain
O2 SAT: 98% strategies manageme strategies
medicatio
. nt .
Assessment of n is
techniques
physical findings: essential
, including
to alleviate
relaxation
 Complaints pain,
and deep
of promoting
breathing
subscapul comfort
exercises.
ar pain and
with a pain 5. Monitor for cooperatio
scale any side n with
rating of effects or treatment.
8/10 at the adverse
operative 3. Comfort
reactions
site. measures
to pain
improve
medication
 Chest X- patient
.
ray well-being
revealing and
left-sided enhance
hemo- the
pneumotho effectiven
rax. ess of
pain
managem
ent.

4. Educating
 the patient
about pain
managem
ent
empowers
them to
participate
actively in
their care.

5. Monitoring
for side
effects
ensures
patient
safety and
optimal
pain relief.

Impaired physical mobility due to presence of CTT 1 way bottle.

ASSESSMEN DIAGNOSI PLANNING INTERVENTI RATIONALE EVALUATION

T S ON

Subjective Impaired After 5 hours 1. Encoura 1. Mobiliza After 5 hours

Data: Physical of nursing ge and tion of nursing
Mobility intervention, assist prevents intervention,
Sustained a due to the the patient will with complic the patient
single stab presence be able to: turning, ations was able to:
wound to the of a Chest positionin such as
left chest in Tube - Demonstr g, and atelecta - Demonstr
the mid Thoracosto ate mobility sis and ate
axillary line. my (CTT) improved exercises improve improved
1-way mobility . s lung mobility
Objective and and
bottle. function.
Data: comfort. 2. Ensure comfort.
2. A well-
- Verbalize the CTT functioni - Verbalize
- Awake
understan 1-way ng CTT understan
and alert
ding of the bottle system ding of the
during
importanc system is ensures importanc
transport
e of secure effective e of
but
mobility and chest mobility
experienci
and functioni drainage and
ng
respiratory ng and lung respiratory
significant
care. correctly. re- care.
pain.
expansi
 3. Administ on.
- Develope er 3. Oxygen
d oxygen therapy
subscapul therapy maintain
ar pain, as s
possibly prescribe adequat
indicating d. e
diaphragm oxygena
atic injury. 4. Educate tion.
the 4. Patient
patient educatio
on the n
significan empowe
ce of rs Marlin
mobility to
and actively
respirator participa
y care. te in her
care.

9. Using a schematic diagram, create a pathogenesis of what will be the effect of stab wound to her lungs
including possible complications.

Stab Wound
to Lungs

Lung Penetration

Hemorrhage

Pneumothorax Hemothorax

Tension Pneumothorax Hypovolemic Shock

Infection Infection

Recurrent Pneumothorax Fibrothorax

 Empyema

Multi-organ Dysfunction

Chronic Pleural Thickening Destruction of Lung Parenchyma

and Lung Abscess

Impaired Lung Mobility

10. What are important nursing management when dealing patients with CTT like Marlin? Explain the
rationale.

The nursing management needed for patient like Marlin, who have undergone with CTT is to take
comprehensive approach to ensure her well-being. Since chest tube thoracostomy is related to lungs, the
nurse should prioritize respiratory assessments. These assessments help us catch any changes in
Marlin's breathing early, allowing for prompt interventions when needed.

We also diligently maintain the CTT system to prevent any issues like disconnections or blockages that
might hinder proper drainage. The nurse should also monitor the volume and the characteristics of
drainage from the chest tube to know if there are any potential complications.

Securing the chest tube adequately and ensuring effective pain management improve Marlin's comfort
and support her respiratory function. Strict adherence to infection control measures minimizes the risk of
infections at the chest tube site. Educating Marlin about her condition empowers her to actively engage in
her care, while continuous vital sign monitoring guarantees timely interventions.

Additionally, offering emotional support plays a crucial role in enhancing Marlin's overall well-being
throughout her recovery process.