Chief Complaint:

Triage level:

Management:

Evaluation:

-Wound on the left hand and a

-3 (Urgent) It requires nursing

-Perform wound care for the puncture

-The left middle finger

bruise on the right shoulder

and physician assessment

wound over the proximal

stopped from bleeding

sustained during an altercation

within 15-45mins of arrival.

interphalangeal joint in the left middle

-The 3-by-4cm

with another teenager 8hr

Justification:

finger using PNSS, water and sterile

ecchymosis present on

earlier today.

-Airway and breathing was not

gauze

the right shoulder

Subjective:

compromised, the vital signs

Rationale: This is to stop the bleeding

decreased to 2-by-3cm.

-Both injuries are human bites

are all within normal range, the

and to protect the finger from any

-Has done no home wound care

patient didnt manifest any

microorganisms that can enter the

-Unable to remember tetanus

alterations in breathing pattern.

blood stream.

toxoid immunization status

Circulation is not impaired also

-Apply cold compress or ice pack on

-Denies past medical problems

but there is a presence of

the right shoulder for patient.

and any history of allergies or

puncture wound over the

Rationale: Cold causes

intravenous drug abuse

proximal interphalangeal joint

vasoconstriction, decreasing blood flow

of the middle finger with a

to an area.

small amount of edema and

-Perform X-ray of the left finger

Objective:

-Average stature and build with

tenderness but no erythema or

Rationale: To locate if there are any

normal vital signs

heat and the patients right

other damage in the finger.

-Puncture wound over the

shoulder has is a 3-by-4-cm

-Perform Complete Blood Count with

proximal interphalangeal joint

ecchymotic region.

differential

of the left middle finger with a

Resources:

Rationale: To determine presence of

small amount of edema and

-X-ray of the left finger was

infection specifically the WBC and

tenderness but no erythema or

obtained

which component is elevated

heat.

-Complete blood Count with

-Test for wound culture

-Has adequate sensation in the

differential was sent

Rationale: In order to determine what

finger and hand

-Injection of Tetanus Diptheria

specific bacteria is present in the

-Has 3-by-4cm ecchymotic

-Antibiotic given

wound.

region on the right shoulder

-Intravenous Fluid therapy

-Give appropriate Antibiotic

with tooth imprints at the

-Possible Admission

Rationale: Antibiotic or antiinfectives

border but skin is not

kills the bacteria present in the wound.

punctured.

-Intravenous Fluid therapy

Rationale: In preparation for the
antibiotic to be given

-Injection of Tetanus Diptheria

Rationale: Td vaccine is used to
protect adolescents and adults from
Tetanus and Diptheria.
-Possible Admission
Rationale: For further monitoring
-Recommend plastic surgery
Rationale: For cosmetic purposes
-Check for the 5 Ps (pain, pulse,
pallor, paralysis, paresthesia)
Rationale: To continuous monitoring
and assessment of the affected area.
-Health teachings imparted as to the
importance of home wound care
Rationale: For early treatment and
prevention of the spread of
microorganism in the body.