JOSE, LEANA LOUISSE D.

BSN 2B1

Case Scenario:

Lester is a 5-year-old, seen in the emergency room after an automobile accident. The child only opens his eye in
response to painful stimuli, he attempts to withdraw from the source of pain upon assessment and he speaks only
in words that makes little or no sense. He has ecchymosis on both periorbital area and behind his ears, has
laceration on his parietal area 3 inches approximately and has rhinorrhea and otorrhea, with multiple abrasion.

Vital signs were taken as follows: FAST

BP:130/90mmHg

PR: 48bpm Therapeutics:

RR: 15cpm IVF: PNSS 1L @ 100cc/hr

Temp: 38.5°C Ceftriaxone 500mg IV OD ANST

Omeprazole 20mg IV OD

The client was for admission and the physician Mannitol 150ml as loading dose then 100ml IV Q6hrs
ordered as follows:
Monitor VS q1
Please admit patient
Monitor NVS q30min
Secure consent for admission and management
Refer accordingly
NPO until further order

ANTI RABIES VACCINATION (ARV)

Diagnostics:
FEB 21 – ONSET
CBC, PC, Typing, PT, APTT

Na, K, Crea, BUN

0 – FEB 21
Cranial CT Scan
3 – FEB 24
Cervical Xray
7 – FEB 28
Thoracic Cage Xray
14 – MARCH 7
Pelvic Xray
28 – MARCH 21
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: STG: INDEPENDENT INDEPENDENT STG:

Risk for After 30mins of 1. Establish rapport 1. To gain trust and Goal Met.
Patient speaks only in Infection nursing 2. Perform hand cooperation of Patient exhibits
words that makes little or related to intervention the hygiene and put the mother a clean, intact
no sense. traumatized patient will on PPE, if 2. Hand hygiene and wound with a
tissue receive wound indicated. PPE prevent the clean dressing
Objective: care and 3. Using sterile spread of in place.
dressing. technique, microorganisms.
 Has laceration on prepare a sterile 3. To maintain LTG:
his parietal area work area & Put surgical asepsis Goal Met.
approx. 3 inches LTG: on sterile gloves and reduces the Patient was
 Rhinorrhea & After 2-3 days of 4. Clean the wound. risk for spreading able to remain
Otorrhea nursing 5. Apply a layer of microorganisms. free from
 Multiple interventions, dry, sterile 4. Cleaning from top infection and
abrasion. the patient dressing over the to bottom and skin irritation as
 V/S taken as wound shows wound center to outside evidenced by
follows: no signs of 6. Check all wound ensures that the wound
infection or dressings every cleaning occurs continues to
BP: 130/90mmHg contamination. shift. More from the least to show signs of
PR: 48bpm frequent checks most progression of
RR: 15cpm Vital signs will may be needed if contaminated healing.
T: 38.5°C go back within the wound is area and a
normal range. more complex or previously Vital signs are
dressings become cleaned area is all normal
saturated quickly not contaminated T: 37.3
again. RR: 22 bpm
DEPENDENT: 5. Primary dressing PR: 80 bpm
serves as a wick
1. Administer for drainage.
Ceftriaxone 6. Checking
500mg IV OD dressings ensures
ANST as ordered the assessment of
2. Administer changes in patient
omeprazole 20mg condition and
IV OD as ordered timely
intervention to
prevent
complications.

DEPENDENT:
1. Wound infections
may be managed
well and more
efficiently with
topical agents and
treat many kinds
of bacterial
infections,
including severe
or life-threatening
forms such as
meningitis.
2. To prevent
acquiring certain
stomach and
esophagus
problems (such as
acid reflux,
ulcers).