Nursing Diagnosis for Trauma Patient

[Naegele]

Hey all,

I've been working on an A&E assignment lately. I was supposed to come up with the 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 traumatized tissue secondary to open wound and closed fracture.

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?

Did I forget anything?

[K+MgSO4, BSN]

spinal management. he has a distracting injury ie the # femur which may be diverting his pain away from an injury to the spine. Full spinal precautions are required until spinal injury can be ruled out.

Being from outside of the Us I haven't the foggiest what NANDA is but if you are doing an essay on Emergency nursing you may need to follow ABCDE D being deformity to r/o a spinal injury and the nursing considerations of that.

Such as hard collar and sandbags and log rolling. How are you going to educate the pt on how to stay still if they are anxious and frightened? to pt safety to prevent further damage, PA care.

Also neuro state? no mention of his GCS - care of the confused or unconscious pt which can lead to protecting an airway.

[Forever Sunshine, ASN, RN]

Your problems that you identified are issues but as with any critical patient you need to focus on airway, breathing and circulation.

He has good oxygen saturation but his blood pressure is very very low. I would chose "Fluid Volume Deficit r/t profuse bleeding from multiple wounds AEB b/p 88/56" and make that my first priority.

[shoegalRN, RN]

I agree with the above poster.

His stats are fine. I will focus on him possible going into hypovolemia shock, which is evident by the increased HR and low BP. Classic symptom of shock.

This should be the priority. Correcting the possibility of him bleeding out. He needs fluids STAT!

Pain should be next. Focus of correcting the underlying problem.

[Naegele]

Thanks for responding~

CGS 15/15. Spinal and cervicle injury has been ruled out.

Temporary skin traction done. ABCED done as well. Whatever I did not mention is clear, airway et cetera...

The three things which need immediate attention were his open wound, bleeding, pain and a fractured femur.

1. Bleeding. Needing fluid replacement and bleeding control, yes I know. I'm refering to the proper way of putting it into a PES nursing diagnosis.

2. Fluid Volume Deficit generally means dehydration. The guideline only refers to water and salt component. Intravenous fluid or blood are not mentioned under this diagnosis.

3. NANDA = North America Nursing Diagnosis Association...I think so...*runs*

[ICURNGUY]

Definitely ABCs: airway was fine, breathing is happening. Was the pt acidotic or alk? This would lead you to fluid def, AEB HR and BP

[casi, ASN, RN]

I think your main problem here is you are stuck on fluid as water.

Think of it this way, what is the main component of blood? *hint* Water+Na.

My book describes Deficient Fluid Volume r/t active fluid volume loss as decreased intravascular, interstitial, or intracelllular fluid; water loss alone without change in sodium. This patient is losing fluids but his electrolytes are probably remaining the same.

related to bleeding you may also look into ineffective tissue perfusion

Also look into labs if you can. I did a lot of care planning based on labs. What are his ABGs? What is his Hgb? Could loss of RBCs be causing the patient to have problems with oxygenation?

[Naegele]

alright, a finalised one for bleeding:

nursing diagnosis: fluid volume deficit related to active body fluid loss secondary to bleeding from open wound as manifested by low blood pressure and rapid pulse.

expected patient outcome: client will have no further blood loss and receive fluid replacement for estimated blood loss as evidenced by increasing blood pressure to normal range (110-120/60-70mmhg) within fifteen minutes after treatment.

sounds okay? what about the impaired skin integrity over risk for infection. my interventions were basically cleaning the wound, removing foreign body, apply antiseptics and applying sterile dressing. deep wounds were sutured but by the medical officers.

[ICURNGUY]

impaired mobility would be a good one as well! r/f infx can be anyone at pretty much any time, even though it's very appropriate.

[Forever Sunshine, ASN, RN]

naegele said:

alright, a finalised one for bleeding:

nursing diagnosis: fluid volume deficit related to active body fluid loss secondary to bleeding from open wound as manifested by low blood pressure and rapid pulse.

expected patient outcome: client will have no further blood loss and receive fluid replacement for estimated blood loss as evidenced by increasing blood pressure to normal range (110-120/60-70mmhg) within fifteen minutes after treatment.

sounds okay? what about the impaired skin integrity over risk for infection. my interventions were basically cleaning the wound, removing foreign body, apply antiseptics and applying sterile dressing. deep wounds were sutured but by the medical officers.

good... now I'd focus on his pain. skin integrity wouldn't be a top concern right now because he is young and his skin would be more likely to heal better than a 90 year old that fell with all these wounds. the wounds still need care so lastly I'd put risk for infection as my 3rd nanda. you can still discuss wound care in your interventions for those.