Fill me UP!

Case:
Julio, a 9-year-old boy fell from his bicycle while making an attempt to
cross the street. He suffered a laceration on his left forearm and it
needs a proper cleaning and wound care.
You received him at 12:00 PM and you started your assessment then.
While interviewing Julio he said “Nurse, my arm hurts! It’s very painful
please help me!!”. Upon further assessment you noted that he has an
open wound 2 cm in size with a serous sanguinous blood secretion
coming out of the wound. His vitals are as follows: RR 30, PR 111 and
temp of 36.4. His pain scale is 8 out of a 0-10 scale.
Date and Time Focus Data
08/10/2020 Laceration Data:
12:00 PM Subjective: “Nurse, my arm
hurts! It’s very painful please
help me!” as verbalized by the
patient.
Objective: Laceration on the left
forearm are with a pain scale of
8 out of 10; 2 cm in size open
wound with serous sanguinous
blood secretion; Temperature of
36.4 C via axilla, respiration 30
breaths per minute, pulse rate
111.

Action: Apply some pressure on

the wound, Antiseptic to the
wound, irrigate the wound with
saline, administered antibiotics
12:10 pm and pain killer as per doctors
order, applied some tissue
adhesive glue, dressed the
laceration with gauze.
Monitoring the wound for
further complication. Tell the
pt’s to avoid rubbing and
scratching the wounds and clip
the nails. Educate the parent and
the children proper nutrition,
hydration, and methods in
maintaining the tissue integrity,
teach skin and wound
assessment ways to monitor for
 sign and symptoms,
complications, and healing,
Instructing the parents and the
Pt wound care.

Response: Patient reports light

relief.

4:00 pm

Name and signature

ANGEL MARIE A. VILLAVERDE,

ADNU Student Nurse, Level II