I've been working on a A&E assignment lately. I was supposed to come up with three most important nursing diagnosis for the trauma patient I've taken care in Red Zone. Here are some of the significant findings from primary and secondary surveys of a patient involved in a motor vehicle accident:
19 male, student.
No past medica/surgical history.
Came in with a deep incised wound at the occipital region.
A deep laceration wound on forehead and lips.
Several abrasion wound over the upper limbs.
Profuse bleeding from incised wound and laceration wounds.
Sustained a closed fracture of right femur.
Complained of severe pain over the fracture and laceration wounds.
Mean respiratory rate, 24 per min. Oxygen saturation 97-99% under regular atmosphere.
Mean pulse, 122 per min.
Blood pressure alarmingly low, 88/56 mmHg.
I've identified three main problems but not sure how to put them into a suitable PES nursing diagnosis
1. Acute Pain related to traumatised tissue secondary to open wound and closed fracture. This is fairly easy.
2. Bleeding. I've looked up the latest NANDA diagnosis, there is no mention of bleeding as one. The closest I could get is Imbalanced Fluid Volume. I find this quite odd as the initial meaning was meant for dehydration. Also, could other diagnosis be more closely related to bleeding such as Impaired tissue perfusion?
3. Open wound. Should I go for Impaired Skin Integrity or Risk for infection? I understand that actual diagnosis has higher priority than risk but what can I do about Impaired Skin Integrity at the emergency department? The doctors were the one who sutured the wound. In this case, does the later diagnosis gain higher priority?
*headache* did I missed out anything?