Alvarez, Kheeney Bae S.

BSN-IVB
RLE- Ward

Name: Armelita Oren

Age: 54 years old
Gender: Female
Hospital Record Number: 1426505
Ward and Bed no: Ward 2, Bed 12
Admitting Diagnosis: Blunt thoracoabdominal injury secondary to blunt chest trauma secondary to vehicular accident
Past medical history:

 No allergies
 no family history of disease
Present medical history:

 Fractured rib
 Closed reduction and possible percutaneous pinning and application
Date of Admission: March 17, 2022
Time of Admission: 7:15 AM
Admitting Physician: Dr. Eunice Yap
Attending Physician: Dr. Sartia Pandangan
 ASSESSMENT NURSING DIAGNOSIS DESIRED GOALS AND NURSING IMPLEMENTATION EVALUATION
OUTCOME INTERVENTION

Subjective: Ineffective breathing At the end of the 6 -Assess quality of -Assessment of Goal: met
“nahihirapan akong pattern related to hours RLE duty, the breath sounds, vital signs and ABC
huminga dahil sa pain and abdominal client will be able to: RR, of patient was -Vital signs:
fractured rib ko” as trauma presence/absence monitored, BP: 130/80 mmHg
verbalized by the - relieved of of cough, and presence/absence PR: 103 bpm
patient discomfort or sputum of cough, and T: 36 c
pain characteristics. sputum RR- 20
“it’s hard to breath - maintain characteristics
because of my normal vital R: Individuals
fractured rib” signs sustaining
abdominal
trauma are likely
Objective: to be tachypneic,
- pain scale of 5/10 with the potential
(moderate pain) for poor
-Shortness of breath ventilatory effort.
If not reversed,
Vital signs: this could result
in atelectasis and
BP- 130/80 mmHg pneumonia.
PR- 108 bpm
T- 36 c -comfortability of -patient verbalized she
RR- 20 Position patient in the patient was feels more comfortable
a semi-Fowler assessed regarding and at ease when
position with the breathing and breathing on a semi-
arms elevated on current position fowlers position
pillows
R: position the
patient for full
-Administered -Patients discomfort
lung expansion
analgesic; and pain was relieved
ketorolac as verbalized and also
Administer evidenced by her facial
analgesics at dose grimace
and frequency
that relieves pain
and associated
impaired chest
excursion.

R: Reducing pain
will enable full
chest excursion Asked patient to
for better use pain scale and -Pain scale of 3 out of
oxygenation. rate the pain on a 10 as verbalized by the
scale of 1 to 10 patient (mild pain)
ask and
encourage the
patient to
describe and rate
the pain on a
scale of 1 to 10 

R:to help evaluate

whether the pain -Established
is being rapport and -Patient is more open
controlled therapeutic to asking questions,
successfully communication open to expressing
 with patients and what she felt during
Emotional family and the vehicular accident
support of the explained why and describing how the
patient and family procedures and accident happened and
R: implementing medications are also how she feels
strategies and done and given staying in the hospital
providing
explanations of
the procedures
reassure the
patient and family

https://nursekey.com/abdominal-trauma/
http://nursing88.blogspot.com/2010/09/nursing-care-plan-ncp-abdominal-trauma.html

Drug Name Mechanism of Action Indications Contraindications Nursing Responsibilities

 Before:
Generic Binds to mu-opioid Relief of mild to - contraindicated with
name: receptors and inhibits moderately severe allergy to tramadol or  Check the Doctors
the reuptake of pain opioids or acute order
Tramadol norepinephrine and intoxication with alcohol,  Assess type, location
serotonin opioids, or psychotropic and intensity of pain
Brand Name: drugs.  Assess for
Adverse effects: - Patients with a history of
Ultram hypersensitivity to
epilepsy or risk factors for tramadol, pregnancy,
CNS: dizziness,
Classification: seizures lactation, and seizures
weakness,
- Renal impairment  Assess for skin color,
headache and
Opioid (increased dosing interval texture, lesions,
drowsiness
Analgesic recommend if CCr <30 mental status, take
CV: orthostatic, ml/min) Vital signs
Dosage: hypotension - Hepatic impairment  Check for the patency
(increased interval of the IV line
50 mg GI: nausea, recommended in patients
anorexia, vomiting, with cirrhosis)
 
diarrhea - Patients receiving MAO During:
Frequency: inhibitors or CNS
GU: polyuria, depressants  Administer with food
q6h nocturia - Increased intracranial or milk to prevent GI
pressure or head trauma upset
  Hematologic: - Acute Abdomen (may  Measure and record
hypokalemia preclude accurate clinical regular weights to
Route: assessment) monitor fluid changes
Local: pain,
- Patients with a history of  Administer drug early
IV phlebitis at
opioid dependence or who in the day so increased
injection site
have recently received urination will not
 disturb sleep
Other: muscle large doses  Control environment if
cramps and muscle - Children <16 years old sweating or CNS
spasm, weakness (safety not established) effects occur
and arthritic pain
After:

 Document and record

 Monitor serum
electrolytes, hydration,
and liver function
during long-term
therapy
 Provide diet rich in
potassium or give
supplemental
potassium
 Ask patient to report if
side effects occur

Drug Name Mechanism of Action Indications Contraindications Nursing Responsibilities

 - Monitor BP upon
Generic name: - Inhibits prostaglandin Short term - Hypersensitivity administration
synthesis, producing management of pain -Drug vials should be
Ketorolac peripherally mediated (not to exceed 5 days -Cross-sensitivity with protected from heat and
analgesia total for all routes other NSAIDS may exist; light
Brand Name: - Has an antipyretic and combined) pre-operative use - Assess for allergies, rhinitis,
anti-inflammatory asthma
Toradol Adverse effects: -Known alcohol
properties - Assess pain (note type,
- Therapeutic effect: intolerance
Classification: location, and intensity) prior
Decrease pain -CNS: drowsiness,
Use cautiously in: to and 1-2 hr following
dizziness, euphoria,
NSAIDS, administration
headache
none-opioid -History of GI Bleeding -Be aware that patient may
analgesic -RESPIRATORY: asthma, be at increased risk for CV
dyspnea -Renal impairment events, GI bleeding, renal
Dosage: (dosage reduction may toxicity monitor accordingly
-CV: edema, pallor, be required)
30 mg
vasodilation
- Cardiovascular disease
-GI: GI Bleeding,
Frequency: Diarrhea, dry mouth,
dyspepsia, GI pain,
q6h nausea

  -GU: oliguria, renal

toxicity, urinary
Route: frequency

IV

https://imgv2-2-f.scribdassets.com/img/document/264889196/original/ce3871afa3/1645360657?v=1
https://d20ohkaloyme4g.cloudfront.net/img/document_thumbnails/ee5f09d1caa3c583e92c0404b7650a6b/thumb_1200_848.png
https://www.scribd.com/doc/174028890/ketorolac-drug-study
Date/ Time Focus Data Action Response

03/17/2022 Ineffective breathing D:

7:30 am pattern related to -pain scale of 4/10 (moderate pain), admitted due to
pain and abdominal blunt thoracoabdominal injury secondary to blunt chest
injury trauma secondary to vehicular accident, Shortness of
breath. “nahihirapan akong huminga dahil sa fractured
rib ko” as verbalized by the patient. “its hard to breath
because of my fractured rib” BP- 130/80 mmHg, PR- 108
bpm, T- 36 c, RR- 20 ______________________________KA
A:
- Assessment of vital signs and ABC of patient was
monitored, presence/absence of cough, and sputum
8: 00 am characteristics, comfortability of the patient was
assessed regarding breathing and current position,
Administered analgesic; tramadol, Asked patient to use
pain scale and rate the pain on a scale of 1 to 10,
Established rapport and therapeutic communication
with patients and family and explained why procedures
and medications are done and given______________KA
R:
- Vital signs: BP: 130/80 mmHg, PR: 103 bpm, T: 36 c
RR- 20, patient verbalized she feels more comfortable
and at ease when breathing on a semi-fowlers position,
Patients discomfort and pain was relieved as verbalized
11:30 am and evident by her facial grimace, Pain scale of 3 out of
10 as verbalized by the patient (mild pain), Patient is
more open to asking questions, open to expressing what
she felt during the vehicular accident and describing
how the accident happened and also how she feels
staying in the hospital __________________________KA