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.

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*

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?