Good morning guys, we are the group assigned to patient Dungdungwen Canto.

So bigay lang
kami ng brief background ng patient He is 35-years-old, a construction worker who accidentally
fell from a ladder, his right forearm hit the shard glass causing stab wound. There are no any
back pain and other injuries also, he did not attempt to remove the large shard in his arm and his
companions only covered the wound with sterile cloth as they transferred the patient for
consultation.
Predisposing factors
Precipitating
According to a report by the National Institute for Occupational Safety and Health. Falls from
heights remain the biggest cause of occupational fatalities in the construction industry. As of
today, 566 out of 1623 occupational deaths in the U.S. were caused by falls, which equals
roughly 35% of all death causes.
Epidermis - the outermost layer of skin, primary function of the epidermis is to act as a physical
and biological barrier to the external environment, preventing penetration by irritants and
allergens.
Dermis - forms the inner layer of the skin and is much thicker than the epidermis, The primary
function of the dermis is to sustain and support the epidermis also to, cushion the body from
stress and strain, and to also provide: elasticity to the skin, a sense of touch, and heat.
Subcutaneous tissue - is the deepest layer of your skin. It's made up mostly of fat cells and
connective tissue. The majority of your body fat is stored here. The subcutaneous layer acts as a
layer of insulation to protect your internal organs and muscles from shock and changes in
temperature.
Yung skin kasi natin it contains nerve fibres/ endings– This sensory nerve endings are found in
the dermis as well as the epidermis (Merkel cells) that allows sensory perception and detect pain,
itch and temperature
Skin Nociceptors (also referred to as pain receptors) are sensory receptors that detect signals
from damaged tissue.
The resulting nerve impulse travels from the sensory nerve ending to the spinal cord, where the
impulse is rapidly shunted to the brain via nerve tracts in the spinal cord and brainstem. The
brain processes the pain sensation and quickly responds with a motor response in an attempt to
cease the action causing the pain.
DX
Assess intensity, description, location, radiation of Helps evaluate degree of discomfort and effectiveness
pain, and changes in sensation. of analgesia or may reveal developing complications
and assessment of pain by conducting an interview
helps the nurse in planning optimal pain management
strategies.
Note nonverbal cues, such as restlessness, facial Body language or nonverbal cues may be both
expression and reluctance to move. physiological and psychological and may be used in
conjunction with verbal cues to determine extent and
severity of the problem.

Bringing attention to associated signs and symptoms

Determine factors that alleviate pain, may help the nurse in evaluating the pain. In some
instances, the existence of pain is disregarded by the
patient.

Changes in these vital signs often indicate acute pain

Observe or signs and symptoms associated with pain,
and discomfort.
such as increased BP, heart rate, temperature, color and
moisture of skin, restlessness, and ability to focus.

TX
Provide comfort measures, such as back rubs, change Improves circulation, reduces muscle tension and
of position, and quiet music or conversation. anxiety associated with pain. Enhances sense of well-
Encourage use of relaxation and breathing exercises. being.

Move client slowly and deliberately, splinting painful Reduces muscle tension and guarding, which may help
area. minimize pain of movement.

Provide quiet environment and reduce stressful stimuli: Promotes rest and enhances coping abilities.
noise, lighting, and constant interruptions.

Maintain comfortable environmental temperature Temperature changes and air movement can cause great
pain to exposed nerve endings

Administer analgesics as indicated Analgesics reach the pain centers immediately,

providing more effective relief with small doses of
medication.
EDx
Encourage expression of feelings about pain. Verbalization allows outlet for emotions and may
enhance coping mechanisms.

Encourage mobilization of the extremities if tolerable. To promote circulation and prevent excessive tissue
pressure.

Encourage use of relaxation techniques: deep-

breathing exercises, guided imagery, visualization, Relieves muscle and emotional tension; enhances sense
music. of control and may improve coping abilities.
 - Acute illnesses generally develop suddenly and last a short time, often only a few days or
weeks.

- Chronic conditions develop slowly and may worsen over an extended period of time—
months to years.

Out of the 6 diagnosis that you've mentioned what is your first prioritize problem
out of the 6-nursing diagnosis and why.

Nasabi kanina na in Full-thickness burn na it affects all the layer of the skin. How
long does it take for skin to heal after full thickness burn?

Ketorolac and Etoricoxib - NSAIDs block a specific enzyme called cyclooxygenase (or
COX) used by the body to make prostaglandins. By reducing production of
prostaglandins, NSAIDs help relieve the discomfort of fever and reduce inflammation
and the associated pain.
- Ketorolac is a non-selective NSAID which, at low doses, has a preferential COX-1
inhibitory effect and etoricoxib is a new selective COX-2 inhibitor.

- Tramadol - is in a class of medications called opiate (narcotic) analgesics.

Superficial burns—3 to 6 days. Superficial partial-thickness burns—usually less than 3 weeks.

Deep partial-thickness burns—usually more than 3 weeks. Full-thickness burns—heal only at the
edges by scarring without skin grafts.

What are the ways to move the patient slowly and deliberately? What are the possible
consequences if the patient does not move slowly and deliberately?
Proper body alignment when moving the patient for example when supporting the patient when
getting up support
Siguro support lng ung patient kung right handed siya tapus d makakain subuan ganoon..tpus
pwede atang mglgy ng sling sa kmy pra d magalaw galaw