Pulmonary

Contusion
Cequina, Patricia Joy
Macias, Daisy Anne
De Guzman, Louie Angelo
Baek, Kum Bee

Introduction

OVERVIEW OF NURSING CARE

Patient ABC was rushed to Mandaluyong City Medical Center

(MCMC) Emergency Room on October 20, 2015 at 3:50 pm with a

chief complaint of multiple stab wounds. Later that day he
undergone Exploratory Thoracotomy (5:30 pm). He was supposed
to be confined in the Intensive Care Unit but unfortunately there
was no vacant room so he was confined at the male surgical ward.
He was on his 6th day of confinement when our group was
assigned to take care of Patient ABC. He was under our care for
three day, from October 26-October 28, 2015. During our care, we
were able to clean his wounds daily, assess his neurological vital
signs, monitored his urine output hourly via IFC, did suctioning,
help lessen his anxiety and so as the family, removed his stitches
& staples (10/28/15) and we were also able to teach the
family/watcher about the importance of good handwashing
technique, wound healing and aspiration precautions.

Patients Date Base

Social History
Patient ABC is a 14 years old male. Born on

July 7, 2001 and he lives on Block 27-Welfare

Compound, Additional Hills, Mandaluyong City.
His height is 5'3 and weighs 45 kg. He is a
grade 7 student in Nueve de Pebrero National
High school. He is a Roman Catholic. He has 3
brothers and 2 sisters, 4 of which are only
step brother and sisters since her mother and
father separated when he was still 3 years old.

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

does not have any special diet. His

usual meal is 2-3 cups of rice and
he usually eats meat products and
seldom eats vegetables. He drinks During hospitalization:
6-8 glasses of water everyday. He
Patient is on NPO since the
is not taking any dietary
day he was admitted
supplements. No problems
(October 20, 2015). He is on
swallowing. His BMI is 17.18 which
meanS he is underweight.
NGT feeding of milk every 4
(Underweight: Your BMI is less than
hours. (8AM, 12PM, 4PM,
18.5. Healthy weight: Your BMI is
8PM
18.5 to 24.9. Overweight: Your BMI
is 25 to 29.9)

Elimination Pattern

Before hospitalization:

Patient defecates 1-3

times per day without any
pain and difficulty. No
problems in urinating.

During hospitalization:

Patient has 1 bowel

movement per day and
usually has 1 diaper
change per day. He also
has aN indwelling Foley
catheter and urine output
monitored hourly

Activity and Exercises

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.

Patient is very dependent to

his mother and brother for
activities of daily living.
Because of the many
contraptions that are
attached to him (such as
mechanical ventilators, CTT,
IV fluids, NGT and ET Tube)
he is always in bed and is
restrained because he might
remove the contraptions.

Sleep Rest Pattern

Before hospitalization:

During hospitalization:

Patient has a regular

sleeping time he usually
sleeps at 9pm and wakes
up at 6am during
weekdays, with a total of
9 hours but during
weekends he sleeps at
1am and wakes up 10pm.
Does not have any
problem in sleeping.

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.

Cognitive Perceptual Pattern

Before hospitalization:

Patient is a seventh grade During hospitalization:

student. Tagalog, is his
Patient has a moderate
primary spoken language.
level of anxiety. has signs
He is mentally oriented
of confusion, still has
and alert with normal
normal hearing and
speech, hearing and
vision .Complains of pain
vision.
in the CTT.

Role - Relationship Pattern

Before hospitalization:

During hospitalization:

Patient still has good

Patient civil status is child. Still
relationship with his family. He
in school, 7th grade. He is the
was always visited by her aunt,
second child among the six.
cousins and friends to support
His support system is his
him and be with him as he was
family. He has a good
in a difficult situation. Their
relationship with his family
main family concern was the
especially his brother. For their
hospital bill, so they asked the
everyday finances the one that
city mayor to help them
supports them is the 2nd live
in partner of their mother since Family has concerns about
his biological father left them
hospital bills so they ask help
when he was 3 years old.
from the city mayor.

Sexuality- Reproductive
Pattern:

During hospitalization:
Before hospitalization:

Patient has a girlfriend

according to his mother.
We werent able to ask if
he was sexually active.

Patient has a girlfriend

according to his mother
but during our care we did
not see his girlfriend visit
him.

Coping Stress Tolerance/ SelfPerception/ Self- Conceptive Pattern

Before hospitalization:

Patient is able to cope

During hospitalization:
with stress he usually
Patient is moderately
hangs out with friends
anxious, and because he
when stressed in school.
is not used with the
Major changes was when
hospital environment. And
his biological after left
according to his mother
them when he was 3 years
his son might have a
old. Her mother said that
trauma because of what
the patient wanted to be a
happened.
policeman in the future

Value- Belief Pattern

During hospitalization:
Before hospitalization:

Patient was baptized as a

Roman Catholic when he
was a baby. He regularly
goes to church with his
older brother.

Patient is still a Roman

Catholic and during our
duty he was visited by a
Pastor. No religious
restriction that would
affect health care and
management.

Family and Past Medical History

For the maternal side they have history of

Hypertension. This is the first hospitalization

of patient.

History of Present
Illness
Few hours prior to admission patient was with

his friends when he was attacked by a drunk

man that caused him to have multiple stab
wounds and was rushed to MCMC ER at
October 20,2015 3:50 pm.

Physical Assessment

Physical Assessment

Physical Assessment

Physical Assessment

Physical Assessment

Physical Assessment

Physical Assessment

Physical Assessment

Anatomy and Physiology

Anatomy and Physiology

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

Implications of the results

to the disease
Decreased HGB, RBC, HTC:
Means anemia. If RBC is
decreased then the amount
of HGB and HTC will also
decrease. This decrease
will cause impaired gas
exchange meaning there
will be less oxygeneated
blood in the body, hypoxia.
(healthline.com)
Decreased Lymphocte:
Low lymphocytes count
indicates that the body is
low on infection resistance.
This means the body is
susceptible to infections
like tumors and cancer. Low
lymphocytes count can also
lead to the damage of
various body organs.
(newhealthline.org)

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

Implications of the results to

the disease
Apulmonary
contusion(orlung contusion)
is acontusion(bruise) of
thelung, caused by chest
trauma. As a result of
damage to capillaries, blood
and other fluids accumulate
in thelungtissue. The excess
fluid interferes with gas
exchange, potentially leading
to inadequate oxygen levels
(hypoxia).
Subcutaneous emphysema
occurs when air gets into
tissues under the skin.
Caused by Collapsed lung
pneumothorax often
occurring with a rib fracture
or stabbing
(nlm.nih.gov)

Arterial Blood Gas (ABG)

Purpose of the Test

As blood passes through

your lungs, oxygen moves
into the blood while carbon
dioxide moves out of the
blood into the lungs. An ABG
test uses blood drawn from
an artery, where the oxygen
and carbon dioxide levels
can be measured before
they enter body tissues
(wedmd.com)

Normal

pH: 7.35-7.45
PCO2: 35-45
PO2: 80-100
HCO3: 22-26
O2 sat: 95-100%

Results

pH: 7.205 (low)

PCO2: 33.5 (low)
PO2: 42 (low)
HCO3: 13.2 (low)
O2 sat: 67.4%

Implications of the results to

the disease
pH: Lower numbers mean
more acidity
PCO2:Someone who is
hyperventilating will "blow
off" more CO2, leading to
lower pCO2 levels
PO2: Anemia
HCO3: Metabolic Acidosis
(glowm.com)
O2 sat: Hypoxemia, or low
blood oxygen, describes a
lower than normal level of
oxygen in your blood. In
order to function properly,
your body needs a certain
level of oxygen circulating in
the blood to cells and
tissues. When this level of
oxygen falls below a certain
amount, hypoxemia occurs
and you may experience
shortness of breath.
(mayoclinic.org)

MEDICAL/SURGICAL
PROCEDURES

Thoracotomy Left Anterio-lateral

Purpose of the Test

Results

Implication

physician gains access to the chest

cavity (called the thorax) by cutting
through the chest wall. Reasons for the
entry are varied. Thoracotomy allows
for study of the condition of the lungs;
removal of a lung or part of a lung;
removal of a rib; and examination,
treatment, or removal of any organs in
the chest cavity. Thoracotomy also
provides access to the heart,
esophagus, diaphragm, and the portion
of the aorta that passes through the
chest cavity
(surgeryencyclopedia.com)

Slowly removing the air in the

pleural space. Remove excess air,
blood, or fluid from& the pleural
cavity

Injury from the multiple stab

wounds caused air to enter the
chest cavity, chest tube is for the
removal of the air or fluid.

Chest Tube Thoracotomy

Purpose of the Test
Tube thoracostomy is the insertion
of a tube (chest tube) into the
pleural cavity to drain air, blood,
bile, pus, or other fluids. Whether
the accumulation of air or fluid is
the result of rapid traumatic filling
with air or blood or an insidious
malignant exuda
tive fluid, placement of a chest
tube allows for continuous, large
volume drainage
(emedicine.medscape.com)
A Simple One - bottle system
It provides water-seal gravity
drainage. The gravity system
allowsthe flow of air or water into
the bottle when the pressure in the
pleuralspace is sufficient to
displace the water in the glass rod.
The long glassrod is submerged
about 2 cm below the water
surface; an intrapleuralpressure
greater than 2 cm in the pleural
space will be required todisplace it.
The reader may demonstrate this
concept by taking a drinking straw
and blowing in through the straw
while it is submerge in a glass of
water. Since the gravity water-seal
drainage bottle is covered with a
stopper, the short glass rod simply

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)

Nasogastric Tube Feeding

Purpose of the Test
Nasogastric (NG) intubation is a
procedure during which a thin,
plastic tube is inserted through
the nostril, down the esophagus,
and into the stomach. Once an NG
tube is in place, healthcare
providers can deliver food and
medicine directly to the stomach
or remove substances from it.
Nasogastric (NG) intubation is
most often used to deliver food
and medicine to a patient when
they are unable to eat or swallow.
(Healthline.com)

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

A blood transfusion is a safe,

common procedure in which blood
is given to you through an
intravenous (IV) line in one of your
blood vessels.
Blood transfusions are done to
replace blood lost during surgery
or due to a serious injury
Red blood cell transfusions are
used to treat hemorrhage and to
improve oxygen delivery to tissues.
Transfusion of red blood cells
should be based on the patient's
clinical condition

After the blood transfusion last

October 20,2015 the result can be
seen for the CBC on October
23,2015 which was good because
it increased .
(10/23/15):(10/20/15)
HGB: 79: 21 (Low)
HTC: 0.23: 0.07 (Low)
RBC: 2.63: 0.79 (Low)
Normal Values
RBC: 4.5-5.4
HTC: 0.38-0.47
HGB: 120-160
Though the results may not be in
within the normal values there has
still been a significant increase
from the last CBC.

Due to lose blood in a injury, anemia is

expected. The physician may require a
transfusion of packed red blood cells,
which means the blood you receive
contains a concentration of mostly red
blood cells.(mayoclinic.com)

Mechanical Ventilator

Purpose of the Test

Results

Implication of the results to the

disease

A method of ventilation in which

airway pressure is maintained
above atmospheric pressure at the
end of exhalation by means of a
mechanical impedance, usually a
valve, within the circuit. The
purpose of PEEP is to increase the
volume of gas remaining in the
lungs at the end of expiration in
order to decrease the shunting of
blood through the lungs and
improve gas exchange.

Airway pressure is kept positive,

and is never allowed to return to
atmospheric . It helped the
patients lungs from collapsing

Lung contusion is the most

frequently diagnosed intrathoracic
injury that results from blunt
trauma. In the early phase of injury,
the impairment of oxygenation
seems to correlate with the
involved lung tissue.Clinically, gas
exchange impairment is obvious.
Respiratory relief can be achieved
by positive-pressure ventilation.
(Pubmed)

Indwelling Folley Catheter

Purpose of the Test

Results

Implication

An indwelling catheter collects

urine by attaching to a drainage
bag. A newer type of catheter has
a valve that can be opened to
allow urine to flow out.
(nlm.nih.gov)

The urine is collected in the

drainage bag.

The patient was in complete bed

rest without bathroom privilages.

MEDICATIONS

1. ALBUTEROL (Accuneb, Apo-Salvent, Gen-salbutamol, Novo-salmol, Proair HFA,

Proventil HFA, Ventodisk, Ventolin GFA, Ventolin nebules, VoSpire ER)
Drug classification: Bronchodilators, adrenergics
Indication: Used as a bronchodilator to control and prevent reversible airway
obstruction caused by asthma or COPD
Common side effect: Nervousness, restlessness, tremor, chest pain, palpitations
Nursing responsibility:
1. Assess lung sounds, pulse, and blood
pressure before administration and during peak of medication. Note amount, color and
character of sputum produced
2. Monitor pulmonary function tests before initiating therapy and periodically during
therapy.
3. Inform the patient that albuterol may cause an unusual and bad taste
4. Advise patient to rinse mouth with water after each inhalation dose to minimize dry
mouth
5. Instruct patient to take albuterol as directed, if on a scheduled dosing regimen take
missed does as soon as remembered, spacing remaining.

2. EPINEPHRINE (Adrenain, Ana-Guard, AsthmaHaler Mist, AsthmaNefrin

(racepinephrine), Epipen, microNefrin, Nephron, Primatene, Sus-Phrine, S-2)
Drug classification: antiasthmatics, bronchodilators, vasopressors, adrenergics
Indication: Management of reversible airway disease due to asthma or COPD.
Common side effect: Nervousness, restlessness, tremor, angina, arrhythnias,
hypertention, tachycardia.
Nursing responsibility:
1. Assess lung sounds, repiratorypattenr, pulse, and blood presire before
administration and during peak of medication. Note amount, color, and character
of sputum produced and notify health care professional of abnormal findings.
2. Monitor pulmonary function tests before and periodically during therapy.
3. Observe for paradoxical bronchospasm (wheezing), If condition occurs withhold
medication and notify health care professional immediately.
4. Assess volume status. Hypovolemia should be corrected prior to administering
epinephrine IV.
5. Medication should be administered promptly at the onset of bronchospasm

3. DOBUTAMINE HYDROCHLORIDE (Dobutrex)

Drug classification: Synthetic catecholamine, Cardiac stimulant
Indication: To treat low cardiac output and heart failure
Common side effect: Nausea, fever, headache, increased blood pressure, irregular
ventricular beats, chest pain
Nursing responsibility:
1. Avoid giving dobutamine to patient with uncorrected hypovolemia, Expect prescriber
to order whole blood or plasma volume expanders to correct hypovolemia, Also avoid
giving dobutamine to patients with acute MI because it can intensity or extent
myocardial ischemia
2. Monitor urine output hourly, as appropriate to assess for improved renal blood flow.
3. Be aware that dobutamine isnt indicated for long-term treatment of heart failure
because it may not be effective and may increase the risk of hospitalization and
death.
4. Monitor hemodynamic parameters such as central venous pressure pulmonary
artery wedge pressure, and cardiac output as indicated to assess drugs effectivenss
5. If hypotension develops, expect to reduce dosage or discontinue drug.

4. DOPAMINE HYDROCHLORIDE (Intropin, Revimine (CAN))

Drug classification: Catecholamine, Cardiac stimulant, Vasopressor
Indication: To correct hypotension that is unresponsive to adequate fluid volume replacement
or occurs as part of shock syndrome caused by bacteremia, chronic cardiac decompensation,
drug overdose, MI, open-heart surgery renal failure trauma, or other major systemic illnesses
to improve low cardiac output.
Common side effect: ectopic heartbeat, tachycardia, angina, palpitation, vasoconstriction,
hypotention, dyspnea, nausea, vomiting,
Nursing responsibility
1. If possible avoid fiving dopamine to patients with occlusive vascular disease such as
atheroclerosis, Buergers disease, diabetic as endarteritis or Raynauds disease, because of
the risk of decrease peripheral circulation.
2. Use drug cautiously in patient with cardiac disease, particularly coronary artery disease
because dopamine increases myocardial oxygen demand, Also use drug cautiously in
patients who are allergic to sulfites, which are contained in some form of dopamine.
3. Monitor urine output hourly as appropriate to assess patient for improved renal blood flow
4. Titrate dopamine gradually to minimize hypotension, especially after a high infusion rate.
5. Inspect parental solution for particles and discoloration before administration

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

6. KETONOLAC (Acular; Toradol)

Drug classification: Analgesic, Nonsteroidal Anti-inflammatory Drug; Anti-inflammatory
Agent;
Indication: Short term (<5days) management of pain usually after surgery
Common side effects: Rash, ringing in the ears, headache, dizziness, drowsiness,
abdominal pain, nausea, diarrhea, constipation, heartburn and fluid retention
Nursing responsibility:
1. Assess pain (note type, location, and intensity) prior to and 1-2hr following administration
2. Ketonolac therapy should always be given initially by the IM or IV route. Oral therapy
should be used only as a continuation of parenteral therapy.
3. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or
other OTC medication without consulting health care professional.
4. Advise patients to consult if rash, itching, visual disturbances, tinnitus, weight gain,
edema, black stools, persistent headache or influenza-like syndrome (Chills, fever, muscle
aches pain) occur.
5. Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients
who do not respond to one NSAIDs may respond to another.

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

9. CEFUROXIME (Ceftin, Zinacef)

Drug classification: Cephalosporin, second generation
Indication: susceptible mild to moderate infections including pharyngitis/tonsillitis, acute
maxillary sinusitis, bronchitis, acute otitis media; uncomplicated skin and skin structure, UTIs,
gonorrhea; early Lyme disease
Common side effects: Nausea, vomiting and diarrhea, kidney problems, diaper rash, yeast
infection, allergic reaction
Nursing responsibility:
1. Assess patient for signs and symptoms of infection prior to and throughout therapy.
2. Before initiating therapy, obtain a history to determine previous use of and reactions to
penicillin or cephalosporins. Persons with a negative history of penicillin sensitivity may still
have an allergic response.
3. Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema,
wheezing). Discontinue the drug and notify physician or other health care professional
immediately if these symptoms occur. Keep throm epinephrine, an antihistamine, and
resuscitation equipment close by the event of an anaphylactic reaction.
4. Instruct patient to report sighs of hypersensitivity.
5. Instruct patient to swallow tablets whole; do not chew or crush as crushed tablet has a
strong, better, persistent taste. Tablets may be taken without regard for food.

10. NALBUPHINE HYDROCHLORIDE (Nubain)

Drug classification: Phenanthrene derivative, analgesic anesthesia adjunct, narcotic
Indication: To relieve moderate to severe pain, As adjunct to anesthesia
Common side effects: dizziness, nausea, vomiting, dry mouth, headache, sedation,
low heart rate, respiratory depression.
Nursing responsibility:
1. Use nalbuphine cautiously in patients tasking other drugs that can cause respiratory
depression.
2. Advise patient to avoid hazardous activities until nalbuphins CNS effects are known.
3. Assess previous analgesic history. Antagonistic properties may induce withdrawal
symptoms (vomiting, restlessness, abdominal cramps, and increased blood pressure
and temperature)
4. Caution patient to change positions slowly to minimize orthostatic hypotension.
5. Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent
atelectasis.

11. DIPHENHYDRAMINE HYDROCHLORIDE (Breadryl, Tusstat)

Drug classification: Antihistamine, second generation, ethanolamine
Indication: to treat hypersensitivity reactions, such as perennial and seasonal
allergic rhinitis, vasomotor rhinitis, allergic conjunctivitis, uncomplicated allergic
skin eruptions, and transfusion reaction.
Common side effects: drowsiness, constipation, diarrhea, dizziness, dry
mouth/nose/throat, headache, anorexia, anxiety, GI upset, asthenia
Nursing responsibility:
1. Explain to the client that arising quickly forms a lying or sitting position may cause
orthostatic hypotension.
2. Provide sugarless candy/gum to diminish dry mouth effects.
3. Before administrating or recommending these drugs, assess for possible
contraindications, including acute asthma or lower respiratory disease that may be
aggravated by drying of secretions, hypersensitivity to antihistamines, glaucoma.
4. Do not use more than 2 weeks to treat insomnia.
5. Take similar doses with meals and at bedtime

12. DIAZEPAM (Valium, Diastat, DiastatAcuDial, Zet)

Drug classification: Antianxiety drug, benzodiazepine
Indication: To relieve anxiety.
Common side effects: Drowsiness (transient), ataxia, confusion
Nursing responsibility:
1. Diazepam interacts with plastic; putting into plastic containers or
administration sets will decrease drug availability.
2. Review anxiety level; identify contributing factors.
3. Drug acts by slowing down the nervous system. Review why prescribed,
dose, form, frequency and desired outcome.
4. Monitor VS, CBC, renal and LFTs. Avoid use with glaucoma (narrow angle)
5. Expect to give a lower dose of diazepam in a patient with chronic
respiratory insufficiency because of the risk of respiratory depression.

13. CEFTAZIDIME (Ceftazidime)

Drug classification: Cephalosporin, third generation
Indication: lower respiratory tract infection, skin and skin structure infection, urinary
tract infection, bacterial septicemia, bone and joint infection, Gynecologic infections,
intra-abdominal infection, central nervous system infection.
Common side effects: nervous, vomiting, diarrhea, yeast infection of the mouth or
vagina, abdominal pain, stomach cramps, colitis, thrombophlebitis.
Nursing responsibility:
1. Do not add ceftazidime to solutions containing aminoglycosides. Give separately.
2. Use cautiously in patients with a history of GI disease, particularly colitis, because
risk of pseudomembranous colitis is increased.
3. Obtain CBC, renal function studies reduce dose with dysfunction.
4. Protect ceftazidime powder and reconstituted drug from heat and light; both tend to
darken during storage.
5. Use ceftazidime cautiously in patients hypersensitive to penicillin because crosssensitivity occurs in about 10% of them. Watch for allergic reactions a few days after
therapy starts.

14. TRAMADOL HYDROCHLORIDE (Ultram)

Drug classification: Cyclohexanol, analgesic
Indication: To relieve moderate to moderately severe pain
Common side effects: abdominal pain, agitation, anxiety, constipation, cough,
diarrhea, drowsiness, dry mouth, fever, headache, heartburn,nausea
Nursing responsibility:
1. Be aware that tramadol shouldnt be given to patients with a history of anaphylactoid
reaction to codeine or other opioids.
2. Avoid giving tramadol to patients with acute abdominal conditions because it may
mask evidence and disrupt assessment of the abdomen.
3. urge patient to follow prescribed dose limits and dosing intervals to prevent
respiratort depression and seizures.
4. Caution patient not to stop tramadol abruptly.
5. If patient develops respiratory depression, expect to give naloxone. Watch for seizures
because naloxone may increase this risk. Take seizure precautions.

15. PNSS (Plain NSS)

Drug classification: Isotonic volume expander, Electrolyte replacement
Indication: Used because it has little to no effect on the tissues and make the person
feel hydrated preventing hypovolemic shock or hypotension
Common side effect: Hypotension, febrile response
Nursing responsibility:
1. Monitor patient frequently for the signs of infiltration/sluggish flow
2. Be aware that hypertonic (1.8%) and hypotonic (0.45%) saline solutions exist.
Ensure appropriate concentration before use.
3. DO not connect flexible plastic containers of IV solutions in series connections. Such
use could result in air embolism due to residual air being drawn from one container
before administration of the fluid from a secondary container is completed.
4. Vented IV administration sets with the vent in the open position should not be sued
with flexible plastic containers
5. Monitor for the signs of phlebitis/infection

16. D5LR (Dextrose 5% in Lactated Linger)

Drug classification: Hypertonic solution
Indication: For replacement of fluids and electrolytes to promote rehydration status to
patient has free water, salt and calories
Common side effect: periorbital, facial, and/orlaryngealedema, coughing,
sneezing, and/or difficulty withbreathing
Nursing responsibility:
1. Monitor for any redness in the insertion site
2. In very low birth weight infants, excessive or rapid administration of dextrose
injection may result in increased serum osmolality and possible intracerebral
hemorrhage.
3. Solution containing dextrose should be used with caution in patients with known
subclinical or overt diabetes mellitus
4. Caution must be exercised in the administration of parenteral fluids especially those
containing sodium ions to patients receiving corticosteroids or corticotrophin
5. Solution containing acetate should be used with caution as excess administration
may result in metabolic alkalosis

17. D5NSS (Dextrose 5% Normal Saline Solution)

Drug classification: Crystaloid, Isotonic Solution
Indication: Ideal for hypotension due to hypovolemia, Vomiting, Shock,
Hyperkalemia, Blood Transfusion.
Common side effects: febrile response, infection at the site of
injection, venous thrombosis or phlebitis extending from the site of
injection, extravasation and hypervolemia.

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.

18. D5W (Dextrose 5% Water)

Drug classification: Water solution and carbohydrate source
Indication: Lactated Ringers and 5% Dextrose Injection, is indicated as a source of
water, electrolytes and calories or as an alkalinizing agent.
Common side effect: Hyperglycemia, Fluid overload
Nursing responsibility:
1. Clinical evaluation and periodic laboratory determinations are necessary to monitor
changes in fluid balance, electrolyte concentrations, and acid base balance during
prolonged parenteral therapy or whenever the condition of the patient warrants such
evaluation.
2. Lactated Ringers and 5% Dextrose Injection, USP should be used with caution.
Excess administration may result in metabolic alkalosis.
3. Caution must be exercised in the administration of parenteral fluids, especially those
containing sodium ions to patients receiving corticosteroids or corticotrophin.
4. Solution containing acetate should be used with caution as excess administration
may result in metabolic alkalosis.
5. If an adverse reaction does occur, discontinue the infusion, evaluate the patient,
institute appropriate therapeutic countermeasures

19. NaHCO3 (Sodium Bicarbonate)

Drug classification: Acidifiers and alkalinizing
Indication: relieveheartburnandindigestion, also used to make the blood and urine
less acidic in certain conditions
Common side effect: Metabolic alkalosis, mood changes, tiredness, shortness of
breath muscle weakness, irregular heartbeat, muscle hypertonicity
Nursing responsibility:
1. Monitor patient closely for toxicity and effectiveness
2. Avoid using NaHCO3 and enteric-coated drugs together
3. Monitor serum electrolyte concentrations, serum osmolality acid-base balance, and
renal function prior to and periodically though out the therapy
4. Assess fluid balance (intake and output, daily weight, edema, lung sounds)
5. Assess for signs of acidosis (disorientation, headache weakness, dyspnea,
hyperventilation), alkalosis (confusion, irritability paresthesia, tetany, altered
breathing pattern), hypernatremia (edema, weight gain, hypertension, tachycardia,
fever, flushed skin, mental irritability), or hypokalemia (weakness, fatigue,
arrhythmias, polyuria, polydipsia)

Nursing Process

Problem #1:Presence of
Intubation Set
Objective Cues: Presence of endotracheal tube, reduced LOC, tube

feedings, poor gag reflex, impaired swallowing.

Subjective Cues: Natatakotakopag para siyangmasamid as
verbalized by the mother.
Nursing Diagnosis: Risk for Aspiration related to presence of
endotracheal tube
Rationale: Aspiration is the entry of secretions or materials such as
food or liquids into the trachea and lungs and occurs when
protective reflexes are decreased or compromised. Aspiration from
the oropharynx into the lungs can result to aspiration pneumonia.
Depending on the acidity of the aspirate, even small amounts of
gastric acid contents can damage lung tissue, resulting in chemical
pneumonitis. Both acute and chronic conditions can place patients
at risk for aspiration.(Gulanick & Myers, 2013)

Problem #1:Presence of
Intubation Set
NOC: Aspiration Prevention
Short Term: After 30 minutes of nursing

intervention, Patients watcher will be able to

demonstrate ways of preventing aspiration
such as keeping the head of bed elevated and
positioning the patient in a 90 angle when
feeding.
Long Term: At the end of the shift, the
patient will maintain a patent airway as
evidenced by absence of coughing, no
shortness of breath, and no aspiration.

Problem #1:Presence of
Intubation Set
Independent:
Monitored level of consciousness; monitored respiratory rate, depth, and effort. Noted any signs of

aspiration such as dyspnea, cough, cyanosis, wheezing, or fever.

Rationale: A decreased in level of consciousness is a prime risk factor for aspiration; Signs of
aspiration should be detected as soon as possible to prevent further aspiration and to initiate
treatment that can be lifesaving. Because of laryngeal pooling and residue in clients with dysphagia,
silent aspiration (i.e., not manifested by choking or coughing) may occur.
Kept the head of the bed elevated at 35-45 and positioned the client in a 90 degree angle when
feeding, whether in bed or in chair or wheelchair. Use cushions or pillows to maintain position.
Rationale: The upright position facilitates the gravitational flow of fluids or food through the
alimentary tract. If the head of the bed cannot be elevated because of the patients condition use a
right-side lying position after feeding to facilitate passage of stomach contents into the duodenum.
Instructed in signs and symptoms of aspiration.
Rationale: Information aids in appropriate assessment of high risk situations and determination of
when to call for further evaluation.
Checked placement and patency of gastric tubes q8h before instillation of feedings.
Rationale: These actions prevent instillation of anything into patients airway.
Assessed presence or absence of gag reflex; assessedfor presence of nausea and vomiting.
Rationale: Lungs are normally protected against aspiration by reflexes such as cough and gag.When
these are absent or reduced, patientis at high risk for aspiration; Nausea or vomiting places patients
at risk for aspiration especially if the level of consciousness is compromised. Antiemetics may be
required to prevent aspiration of regurgitated contents.

Problem #1:Presence of
Intubation Set
Dependent:
Administer Omeprazole 40 mg x OD, as ordered by the physician.

Rationale: A Gastric acid secretion inhibitor; Treatment of gastric

ulcers, GERD, pathological hypersecretory syndromes; maintenance
therapy for healing duodenal ulcers and esophagitis, treatment of
heartburn or symptoms of gastroesophageal reflux.
Evaluation
Short Term: Goal Met. After 30 minutes of nursing intervention,
Patients watcher demonstrated ways of preventing aspiration such
as keeping the head of bed elevated and positioning the patient in a
90 angle while feeding.
Long Term: Goal Met. At the end of the shift, the patient maintained
a patent airway as evidenced by having no episodes of aspiration.

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.

Rationale: Used as a bronchodilator to control and prevent

reversible airway obstruction caused by asthma or COPD
Evaluation
Short Term:Goal Met. After 1 hour of nursing intervention
patientmaintainedan adequate O2 saturation rate of 98-99%
with the assistance of the mechanical ventilator.
Long-Term: :Goal Partially Met.After 2 days of nursing
intervention, patient maintained a normal range of O2
saturation (95-100%) with mechanical ventilator and
manifested a decrease in respiratory rate from 36 bpm to 33
bpm and did manifest any signs of respiratory complications.

Problem #3: Pain

Objective Cues: Facial grimacing and wincing, agitation,

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)

Problem #3: Pain

NOC: Relieve Pain
Short-Term Goal: After 1 hour of nursing

intervention, patient will manifest a decrease of

pain as evidenced by a more relax facial
expression, 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: Within the shift, patient will not
experience more pain and will maintain a relax
facial expression.
NIC: Pain Management

Problem #3: Pain

Independent
Evaluated the effectiveness of all pain management, including medication and nonpharmacological

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.

Problem #3: Pain

Dependent:
Administered Tramadol 250 x 24 TIV, as ordered by the

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.

Problem #4: Agitation

Objective Cues: Tachycardia, apprehensive, facial tension, poor

eye contact, moderate level of anxiety.

Subjective Cues: Natatakotakopag para siyangmasamid. As
verbalized by the mother.
Nursing Diagnosis: Anxiety related to trauma
Rationale: Emotional response to environmental stressors and is
therefore part of the persons stress response. Each individuals
experience with anxiety is different. Some people are able to use
emotional edge that anxiety provokes to stimulate creativity or
problem-solving abilities; others can become immobilized to a
pathological degree these includes anxiety disorders such as
panic attacks and post-traumatic stress disorder. Mild anxiety can
enhance a persons perception of the environment and readiness
to respond.(Gulanick & Myers, 2013)

Problem #4: Agitation

NOC: Anxiety Self-Control
Short Term: After 30 minutes of nursing

intervention, patient will demonstrate

observable signs of reduced anxiety such as
reduced facial tension.
Long Term: After the shift, the patient will
cope with current medical situation without
demonstrating any signs of anxiety.
NIC: Anxiety Reduction

Problem #4: Agitation

Independent:
Assessed the patients anxiety level. Note any signs and symptoms, especially nonverbal

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.

Problem #4: Agitation

Dependent:
Administered Diazepam 50 mg, as ordered by the

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.

Problem #5: Multiple Stab

Wounds (October 20, 2015)
Objective Cues: Presence of stab wounds (8 cm on left knee,
2 cm on side of left knee, 6 cm on RLQ of the abdomen, and 21
cm, 6 cm and 3cm on thoracic area), wounds are dry and intact
except wound on the left knee, Presence of CTT.
Subjective Cues:
Natatakotakonabakabumukaangmgasugatniya. As verbalized
by the patients aunt.
Nursing Diagnosis: Impaired Skin Integrity related to stab
wounds
Rationale:Impaired skin integrity is not a frequent problem for
most healthy people but is a threat to older adults; to clients
with restricted mobility, chronic illnesses, trauma; and to those
undergoing invasive health care procedures. (Berman & Snyder,
2014)

Problem #5: Multiple Stab

Wounds
NOC: Wound Healing
Short-Term Goal: After 30 minutes of

nursing intervention, patients watcher will

demonstrate interventions on how to properly
take care of the stab wounds such as wound
cleaning and change of dressing.
Long-Term Goal:After 3 days of nursing
intervention, the patient will manifest timely
healing of the wound such as absence of fever
and dry wound.
NIC: Wound Care

Problem #5: Multiple Stab

Wounds
Independent:
Assessed site of skin impairment and determined cause.

Rationale: The cause of the wound must be determined before appropriate

interventions can be implemented. This will provide the basis for additional testing and
evaluation to start the assessment process).
Warned against tampering with wound or dressing.
Rationale: To reduce potential infection.
Monitored the clients skin care practices, noting type of soap or other cleansing
agents used, temperature of water, and frequency of skin cleansing.
Rationale: Cleansing should not compromise the skin.
Reinforced initial dressing or changed, as indicated. Used aseptic technique.
Rationale: Protects wound from injury and contamination, prevents irritation of skin
that may be a possible entry of microorganisms.
Positioned client for comfort and minimal pressure on bony prominences. Change his
position at least every two hours.
Rationale: Monitor frequency of turning and skin condition, these measures reduces
pressure, promote circulation, and minimize skin breakdown.
Supervised patient and his family in skin care regimen. Provided feedback.
Rationale: Practice helps improve skill in managing patient skin care regimen.

Problem #5: Multiple Stab

Wounds
Evaluation
Short-Term: Goal Met. After 30 minutes of

nursing intervention, patients watcher

demonstrated ways on how to properly care of
wounds such as wound cleaning and wound
dressing.
Long-Term:Goal Met. After 3 days of nursing
intervention, the patient manifested timely
healing of the wound such as dry wound and
absence of fever.

Summary and Conclusion

Pulmonary contusion is a common thoracic injury defined as damage to the
lung tissues resulting in hemorrhage and localized edema. This blunt lung
injury develops over the course of 24 hours, leading to poor gas exchange,
increased pulmonary vascular resistance and decrease lung compliance.

When caring patient with pulmonary contusion, it is important to maintain the

airway, providing adequate oxygenation, and controlling of pain as priority.
Appropriate management and treatment is needed. It was truly lamentable
to hear that our patient passed away after our shift. We as nurses must do
our best to provide strong emotional support to accept present state to
patient and patients family. It is necessary to provide comfort and rest,
reduce stress.

Pulmonary contusion usually resolves itself without causing permanent

complications. However it may also have long term ill effect on respiratory
function. Most contusion resolves in five to seven days after injury.