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PATIENTS ASSESSMENT

WITH VACULAR INJURIES IN ACCIDENT AND EMERGENCY WARD 2

SRINAGARIND HOSPITAL KHON KAEN

A. IDENTITY

Name/ Initial : Mr. S

Age : 25 Years Old

Religion : Buddhist

Marital Status : Single

Sex : Male

Education : Bachelor

Occupation : Engineer

Nationality : Thai

Address : Lopburi

Reg. Number : JD4628

B. HEALTH STATUS

1. Health History

Mr. S is 25 years old. He is a engineering staff in the bank in Khon Kaen.

He lives with his parent. The major reason for seeking health care in

Srinagarind hospital at December, 2015 is because he got accident and

occur the open fracture and also the vascular injuries at his left proximaltibia. The patient is referral from Khao Kho Hospital. Patient’s height is

170 and his weight is 68. Vital sign in January 21, 2016: Blood pressure is

102/52 mmHg, Pulse is 80 times/minute, Respiration rate is 20

times/minute, Temperature is 37,8º C.

2. Past Illnesses/ hospitalizations

Patient got accident when he does traveling go to Khon Kaen from lopburi

at December 30, 2015. He was brought his family to the Khao Kho

hospital before he was referred to the Srinagarind Hospital.

3. Allergies

The care giver said that the patient does not have allergy from foods,

drinks or drugs.

4. Developmental Histories

Admission Date: December 31, 2015

Assessment date: January 23, 2016

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The patient said that he has gone through two surgeries, and later on a

third operation will be performed skin graft. He said that his wound on the

left foot. The first surgery is wound exploration and debridement, and the

second surgery is Open Reduction and Internal Fixation (ORIF) procedure.He looks lying on the bed, He can not walk by him self. The

documentation explained that the patient has fracture and occur vascular

injury in his tibia (left side). The patient said that feels pain in his surgical

wound. The nurse said that the patient skin in wound area looks red and

the surgical wound has infection. The patient wound looks bandaged.

C. FUNCTIONAL HEALTH PATTERN (GORDON)

1. Health perception/ health management patternThe Patient has care giver who always take care of him. The care giver is

his mother. He hope can go home as soon as possible. He said that He does

not drink alcohol and does not use tobacco. He exercises regularly before

get accident.

2. Nutritional/metabolic

Patient said that eats regularly 3 times before going to hospital and

admitting in hospital. There is no problem with his nutrition pattern.

3. Elimination pattern

Bowel habits: The patient said that does not problem with bowel pattern.

The bowel habit of patient is once in 1-2 days. Patient does not have

diarrhea and/or constipation.

Bladder habits: The patient said that he does not problem with bladder

pattern, patient go to toilet is accompanied his mother for urinary

elimination.

4. Activity exercise pattern

The patient said that he is only bed rest. The patient said that he feels pain if 

try to lift his foot (left side). The patient eats by him self and uses assistive

device if he want to go to the toilet, to mobility and ambulate.

Self Care Ability

Activity Score

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Eating 0

Bathing 0

Dressing 0

Toileting 0

Bed mobility 0

Ambulating 3

Cooking 40 = independent, 1 = assistive device, 2 = assistance from other, 3 = assistance from

other and equipment, 4 = dependent/ unable.

 

5. Sexuality reproductive pattern

The patient does not get married yet.

6. Sleep/rest pattern

The patient looks bed rest. He said that does have enough sleep. The patient

looks not relax cause of his pain.

7. Sensory/perceptual pattern

The patient can see clearly to the people, he does not use eyes glasses and

he has no problem in his ears. He does not wear any hearing aids. The

patient also can feel when the nurse touch his skin and his fingers.

Patient does not have neurological history before.

Patient said that has pain on the left lower extremity with:

P: surgical wound, fracture.

Q: Stabbing

R: on left foot

S: 6 (Moderate Pain)

T: when moving and wound care.

The patient looks grimacing in pain.

8. Cognitive pattern

The patient said that does not knowledge about vascular injury and its

complication. The patient and care giver look confuse when the nurse

ask to discuss about patient’s disease.

9. Role/relationship pattern

The patient has gotten caring from his mother. His mother is taking care for

24 hours. The care giver said that their house is far from hospital, so only

she who can stay in hospital to accompany the patient.

10. Value belief patternReligious orientation is Buddhist.

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11. Coping/stress tolerance pattern

The care giver said that the patient never complain with his condition.

D. Wound AssessmentT = Tissue non viable

I = Infection and/or inflammation,

M = Moisture imbalance

E = non-advancing or undermined

E. SUPPORTED ASSESSMENT

Laboratory Investigation

No Test Result Normal interpretatio

n

1 HB 11,3 Men : 14-18 gr/dl Anemia

2 HCT 34 Men : 40-48%

3 WBC 9700

4 PLT 457K

5 PMN 82,3

6 Lympho 23 20-35%

7 Mono 9,4 2-8%

8 Eos 4,6 1-4%

9 Baso 0,7 0-1%

Medication

1. Morphine 0,1 mg

2. Tramal 50 Mg. IV PRN 4 hr.

3. Onsia 8 mg. IV PRN 6 hr.

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DATA ANALYZE

No. Data Etiology Problem

1 SD:

The patient said that he feels

pain if try to lift his foot (left

side).

Patient said that has pain on

the left lower extremity with:

P: surgical wound,

fracture.

Q: Stabbing

R: on left foot

S: 6 (Moderate Pain)

T: when moving and

wound care

OD:

Blood pressure is 102/52

mmHg, Pulse is 80

times/minute, Respiration rate

is 20 times/minute,

Temperature is 37,8º C.

The patient looks not relax

The patient looks grimacing

in pain

Surgical Wound

Contaminated

Bacteria

Inflamation

Pain

Acute Pain related

to surgical wound

infection

Definition:

Acute pain is

sensory and

emotional

experiences which

are not interesting

that appear because

of actual or

potential tissue

damaging and the

time is less than 6

months.

2 SD: Accident/ over Integrity of skin

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Patient said that the wound on

his left foot

The documentation explained

that the patient has fracture

and occur vascular injury in

his tibia (left side)

OD:

Patient has surgical wound on

his left foot.

The nurse said that the patientskin in wound area looks red

and the surgical wound has

infection

The patient’s wound looks

bandaged.

Wound Assessment

T = Tissue non viable

I = Infection and/or

inflammation,

M = Moisture

imbalance

E = non-advancing or

undermined

pressure to the Os.

Tibia directly

Open Fracture and

vascular injury

Inflamation

Pain

disorder related to

the open fracture

Definition:

Integrity skin of 

disorder is disorder

of dermis,

epidermis and body

structure invasy.

3 SD:

The patient said that he has

gone through two surgeries

He said that his wound on the

left foot.

The documentation explained

that the patient has fracture

and occur vascular injury in

his tibia (left side).

The patient said that feels

pain in his surgical wound.

Surgical Wound

Contaminated

Bacteria

Infection

Infection related to

infected of  

microorganism

pathogenic.

Definition:

Infection is

infected of  

microorganism

pathogenic

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OD:

The nurse said that the patient

skin in wound area looks red

and the surgical wound  has

infection.

Temperature is 37,8º C.

Hb:11,3

4 SD:

The patient said that he is

only bed rest. The patient said that he feels

pain if try to lift his foot (left

side).

The patient eats by him self 

and uses assistive device if he

want to go to the toilet, to

mobility and ambulate.

The patient said that go to

toilet is accompanied his

mother for urinary

elimination.

OD:

The patient looks bed rest.

The patient looks not relax

cause of his pain.

The open Fracture,

vascular injury

Surgical procedure

Physical limitation

Immobility

Immobility related

to vascular injury,

destruction of bonetissue

Definition:

Immobility is

limitation physic

mobility

independently

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SD:

The patient said that does not

knowledge about vascular

injury and its complication.

OD:

The patient and care giver

look confuse when the nurse

ask to discuss about patient’s

disease.

Few of information

About patient’s

disease

Knowledge

deficiency

Patient and family

knowledge

deficiency related

to few of  information

Definition:

Knowledge

deficiency

is information

which associated

with the disease

NURSING DIAGNOSE

1. Acute Pain related to surgical wound infection

2. Integrity of skin disorder related to the open fracture

3. Infection related to infected of microorganism pathogenic.

4. Immobility related to vascular injury, destruction of bone tissue

5. Patient and family knowledge deficiency related to few of information

NURSING ONTERVENTION

No. Nursing diagnose Purpose and results criteria Nursing

intervention

1 Acute Pain related to

surgical wound

infection

NOC

Pain control

With results criteria:

NIC

1. Teach patient

hoe to do pain

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SD:

The patient said

that he feels pain if 

try to lift his foot

(left side). Patient said that

has pain on the left

lower extremity

with:

P: surgical

wound,

fracture.

Q: Stabbing

R: on left

foot

S: 6

(Moderate

Pain)

T: when

moving and

wound care

OD:

Blood pressure is

102/52 mmHg,

Pulse is 80

times/minute,

Respiration rate is

20 times/minute,

Temperature is

37,8º C.

The patient looks

not relax

The patient looks

grimacing in pain

SD:

Patient said the pain less

(Scale 1-3) and/ no pain

Patient said that he candoes pain management

OD:

Patient looks relax

Patient looks smile

management

non-

pharmacology,

such as

listening themusic,

sleeping, and

talking with

others

2. Identify cause

of pain

3. Identify when

the pain

4. Solve the

causes that

increase the

pain

5. Collaboration

to give

analgesic

2 Integrity of skin

disorder related to the

open fracture

SD:

Patient said that

NOC

Tissue skin and mucous

membrane integrity

With results criteria:

SD:

NIC

1. Wound care

effectively

2. Monitor of the

wound and

skin

3. Monitor

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the wound on

his left foot

The

documentation

explained thatthe patient has

fracture and

occur vascular

injury in his

tibia (left side)

OD:

Patient has

surgical woundon his left foot.

The nurse said

that the patient

skin in wound

area looks red

and the surgical

wound has

infection

The patient’swound looks

bandaged.

Wound

Assessment

T = Tissue

non viable

I =

Infection and/or

inflammation,

M =

Moisture

imbalance

E = non-

advancing or

undermined

Patient said that the

wound has already

healing

OD: The wound on patient left

foot is not infection and

in process to be healing

patient

nutrition status

4. Monitor sign

of infection on

wound

3 Infection related to

infected of  

microorganismpathogenic.

NOC

Immune status

Knowledge: infection controlWith results criteria:

NIC

1. Monitor signs

of infectionfrom wound

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SD:

The patient said

that he has gonethrough two

surgeries

He said that his

wound on the left

foot.

The documentation

explained that the

patient has fracture

and occur vascularinjury in his tibia

(left side).

The patient said

that feels pain in

his surgical

wound.

OD:

The nurse said thatthe patient skin in

wound area looks

red and the

surgical wound has

infection.

Temperature is

37,8º C.

Hb: 11,3

SD:

The patient said that the

feels good and no fever

OD:

The wound is not

infection

Hb is around 14-18 gr/dl.

Temperature is normal

2. Collaboration

to give

antibiotic

powder to

wound3. Do infection

control such as

sterilization

technique,

wash hand

before and

after contact

with patient

4. Monitor WBC5. Collaboration

for giving

antibiotic

6. Collaboration

to give vitamin

for

hemoglobin

7. Monitor hb

score

4 Immobility related to

vascular injury,

destruction of bone

tissue

SD:

The patient said

that he is only bedrest.

NOC

Joint movement mobility level

Self care ADLs

With results criteria:

SD:

The patient said that he

can do activity and moveby him self

NIC

1. Discuss to give

tools

ambulatory to

the patient

2. Teach patient

how to

ambulatory

technique

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The patient said

that he feels pain if 

try to lift his foot

(left side).

The patient eats byhim self and uses

assistive device if 

he want to go to

the toilet, to

mobility and

ambulate.

The patient said

that go to toilet is

accompanied hismother for urinary

elimination.

OD:

The patient looks

bed rest.

The patient looks

not relax cause of 

his pain.

OD:

Mobility level is less than

10 score

Patient look mobile byhim self 

3. Identify patient

ability to do

mobilization

4. Collaboration

to do physicaltherapy

5. Identify and

monitor of  

mobility level

5 Patient and family

knowledge deficiency

related to few of  

information

SD:

The patient said

that does not

knowledge aboutvascular injury and

its complication.

OD:

The patient and

care giver look 

confuse when the

nurse ask to

discuss aboutpatient’s disease.

 Knowledge: disease

Knowledge: health behavior

With results criteria:

 DS

The care giver said that

she understand about

diabetes and how to

prevent it

The care giver said that

she can do wound care if 

the patient goes home

The patient said that he

understand about his

disease.

OD:

The patient and care giver

1. Teach patient

and family

about patient’s

disease

2. Teach patient

and family

how to do

wound care to

the patient

3. Do discussion

about the

disease and

how to care

about the

disease

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look cooperative and can

answer the nurse

questions about fracture

and vascular injury.