Acute pain related multiple physical injury AEB pain scale of 4/10 and multiple lacerations in left

eyebrow, tympanic area, right zygomatic cheek area and in the philtrum.
SUBJECTIVE DATA
The patient verbalized "ang sakit ng mga sugat ko"
Pain scale of 4/10

OBJECTIVE DATA:
- lacerations in left eyebrow, tympanic area, right zygomatic cheek area and in the philtrum.
- grimace
-restlessness
-weakness
-irritability

Short Term Objectives

After 4 hours of nursing intervention the patient will able to
- Report satisfactory pain control with pain scale of 4/10 to 2/10
- Engage in desired activities without an increase in pain level.
- Use the skills of relaxation and entertainment activities as a pain control

INDEPENDENT
1. Assess pain, noting location, characteristics and severity.
2. Monitor skin color and vital signs
3. Assist on wound care
4. Provide back rub or position the client to her comfortable position
5. Instruct the use of relaxation exercises such as pursed lip breathing
6. Encourage diversional activities such as watching tv’s or socializing with others
7. Encourage adequate rest periods
DEPENDENT
8. Administer Ketorolac as order
 9. Administer analgesia before painful procedures as ordered

- Useful in monitoring effectiveness of medication, progression of healing. Changes in

characteristics of pain may indicate developing abscess/peritonitis, requiring prompts
medical evaluation and intervention
- Hr, bp, respirations
- To provide a clean wound resulting to faster wound healing, preventions of infection
and decrease in pain sensation.
- To provide comfort and relaxation
- To provide comfort
- To divert attention from pain
- To prevent fatigue
- Doing so will help prevent pain caused by relatively painful procedures
(e.g., wound care, venipunctures, chest tube removal, endotracheal
suctioning, etc.).
•

Impaired Skin Integrity related to skin destruction secondary to vehicular accident AEB redness, pain on
the affected area and moist wound

SUBJECTIVE DATA
"May mga sugat ako at nakakaramdam parin ako ng sakit” as verbalized by the patient

OBJECTIVE DATA:
- lacerations in left eyebrow, tympanic area, right zygomatic cheek area and in the philtrum.
- redness
-pain on the affected area
-moist wound

Short Term Objectives

After 4 hours of nursing intervention the patient will able to

- Verbalize understanding on his condition

- Demonstrate techniques/behaviors changes to promote healing and prevent complications
Long Term Objective

After 1 week of nursing intervention the patient will able to

- Demonstrate progressive improvement in wound healing AEB presence of lacerations, redness

and pain.

INDEPENDENT

1. Inspect wounds or lesions daily for changes

2. Assist patient on wound care
3. Promote good nutrition with adequate protein such as fish
4. Provide adequate periods of rest and sleep
5. Instruct patient and significant others to practice aseptic technique
6. Instruct the patient to avoid rubbing and scratching
7. Teach patient and significant other about skin and wound assessment
and ways to monitor for signs and symptoms of infection,
complications, and healing.
DEPENDENT

8. Administer Cefuroxime as ordered

COLLABORATIVE

9. Ensure adequate dietary intake and review dietitians recommendations.

Short Term Goal

Goal met

After 4 hours of nursing intervention the patient was able to:

- Verbalize understanding on his condition

- Demonstrate techniques/behaviors changes to promote healing and prevent complications AEB
by practice aseptic technique and taking the ordered medicine

Long Term Goal

After 1 week of nursing intervention the patient was able to

- Demonstrate progressive improvement in wound healing AEB decerease of lacerations, redness

and pain.
Rubbing and scratching can cause further injury and delay healing.
Risk for infection r/t altered skin integrity AEB increased WBC and Neutrophils and decreased of
lymphocytes

SUBJECTIVE DATA:

The patient verbalized “Hindi pa gumagaling ang mga sugat ko”

OBJECTIVE DATA:

- lacerations in left eyebrow, tympanic area, right zygomatic cheek area and in the
philtrum.
- WBC- 14.64
- Neutrophils-12.70
- Lymphocytes- 8 %

Short Term Objectives:

After 4 hours of nursing intervention the patient will able to:

- Demonstrate behaviors/ lifestyle for wound healing

- Demonstrate techniques to reduce risk for infection

Long Term Objective

After 1 week of nursing intervention the patient will be able to:

- Free from any signs of infection

INDPENDENT

1. Monitor vital signs

2. Monitor laboratory result especially WBC
3. Maintain strict asepsis for dressing changes and wound care
4. Ensure that any articles used are properly disinfected or sterilized
before use.
5. Instruct significant others to wash hands or perform hand hygiene
before having contact with the patient.
 6. Encourage coughing and deep breathing exercises; frequent position
changes.
7. Promote nail care by keeping the client and the nurse‘s fingernails
short and clean.
8. Limit visitors.

INDEPENDENT

9. Administer Cefuroxime as ordered

COLLABORATIVE

10. Collaborate with the dietitian in preparing a protein-rich and calorie-rich foods.

Short Term Goal

Goal Met

After 4 hours of nursing intervention the patient was able to:

- Demonstrate behaviors/ lifestyle for wound healing AEB taking medication as ordered
- Demonstrate techniques to reduce risk for infection AEB maintaining asepsis

Long Term Goal

After 1 week of nursing intervention the patient was able to:

- Free from any signs of infection AEB wound is slowly healing