PATIENTSASSESSMENT

WITHVACULARINJURIESINACCIDENTANDEMERGENCYWARD2
SRINAGARINDHOSPITALKHONKAEN
A. IDENTITY
Name/Initial
Age
Religion
MaritalStatus
Sex
Education
Occupation
Nationality
Address
Reg.Number

:Mr.S
:25YearsOld
:Buddhist
:Single
:Male
:Bachelor
:Engineer
:Thai
:Lopburi
:JD4628

Admission Date: December 31, 2015

Assessment date: January 23, 2016

B. HEALTHSTATUS
1. HealthHistory
Mr.Sis25yearsold.HeisaengineeringstaffinthebankinKhonKaen.
He lives with his parent. The major reason for seeking health care in
SrinagarindhospitalatDecember,2015isbecausehegotaccidentand
occurtheopenfractureandalsothevascularinjuriesathisleftproximal
tibia.ThepatientisreferralfromKhaoKhoHospital.Patientsheightis
170andhisweightis68.VitalsigninJanuary21,2016:Bloodpressureis
102/52 mmHg, Pulse is 80 times/minute, Respiration rate is 20
times/minute,Temperatureis37,8C.
2. PastIllnesses/hospitalizations
PatientgotaccidentwhenhedoestravelinggotoKhonKaenfromlopburi
at December 30, 2015. He was brought his family to the Khao Kho
hospitalbeforehewasreferredtotheSrinagarindHospital.

3. Allergies
Thecaregiver saidthatthepatientdoesnothaveallergyfromfoods,
drinksordrugs.
4. DevelopmentalHistories

Thepatientsaidthathehasgonethroughtwosurgeries,andlaterona
thirdoperationwillbeperformedskingraft.Hesaidthathiswoundonthe
leftfoot.Thefirstsurgeryiswoundexplorationanddebridement,andthe
secondsurgeryisOpenReductionandInternalFixation(ORIF)procedure.
He looks lying on the bed, He can not walk by him self. The
documentationexplainedthatthepatienthasfractureandoccurvascular
injuryinhistibia(leftside).Thepatientsaidthatfeelspaininhissurgical
wound.Thenursesaidthatthepatientskininwoundarealooksredand
thesurgicalwoundhasinfection.Thepatientwoundlooksbandaged.
C. FUNCTIONALHEALTHPATTERN(GORDON)
1. Healthperception/healthmanagementpattern
ThePatienthascaregiverwhoalwaystakecareofhim.Thecaregiveris
hismother.Hehopecangohomeassoonaspossible.HesaidthatHedoes
notdrinkalcoholanddoesnotusetobacco.Heexercisesregularlybefore
getaccident.
2. Nutritional/metabolic
Patient said that eats regularly 3 times before going to hospital and
admittinginhospital.Thereisnoproblemwithhisnutritionpattern.
3. Eliminationpattern
Bowelhabits:Thepatientsaidthatdoesnotproblemwithbowelpattern.
The bowel habit of patient is once in 12 days. Patient does not have
diarrheaand/orconstipation.
Bladder habits: The patient said that he does not problem with bladder
pattern, patient go to toilet is accompanied his mother for urinary
elimination.
4. Activityexercisepattern
Thepatientsaidthatheisonlybedrest.Thepatientsaidthathefeelspainif
trytolifthisfoot(leftside).Thepatienteatsbyhimselfandusesassistive
deviceifhewanttogotothetoilet,tomobilityandambulate.
SelfCareAbility
Activity

Score

Eating
Bathing
Dressing
Toileting
Bedmobility
Ambulating
Cooking

0
0
0
0
0
3
4

0=independent,1=assistivedevice,2=assistancefromother,3=assistancefrom
otherandequipment,4=dependent/unable.

5. Sexualityreproductivepattern
Thepatientdoesnotgetmarriedyet.
6. Sleep/restpattern
Thepatientlooksbedrest.Hesaidthatdoeshaveenoughsleep.Thepatient
looksnotrelaxcauseofhispain.
7. Sensory/perceptualpattern
Thepatientcanseeclearlytothepeople,hedoesnotuseeyesglassesand
hehasnoprobleminhisears.Hedoesnotwearanyhearingaids.The
patientalsocanfeelwhenthenursetouchhisskinandhisfingers.
Patientdoesnothaveneurologicalhistorybefore.
Patientsaidthathaspainontheleftlowerextremitywith:
P:surgicalwound,fracture.
Q:Stabbing
R:onleftfoot
S:6(ModeratePain)
T:whenmovingandwoundcare.
Thepatientlooksgrimacinginpain.
8. Cognitivepattern
Thepatientsaidthatdoesnotknowledgeaboutvascularinjuryandits
complication.Thepatientandcaregiverlookconfusewhenthenurse
asktodiscussaboutpatientsdisease.
9. Role/relationshippattern
Thepatienthasgottencaringfromhismother.Hismotheristakingcarefor
24hours.Thecaregiversaidthattheirhouseisfarfromhospital,soonly
shewhocanstayinhospitaltoaccompanythepatient.
10. Valuebeliefpattern
ReligiousorientationisBuddhist.

11. Coping/stresstolerancepattern
Thecaregiversaidthatthepatientnevercomplainwithhiscondition.
D. WoundAssessment
T
I
M
E

=Tissuenonviable
=Infectionand/orinflammation,
=Moistureimbalance
=nonadvancingorundermined

E. SUPPORTEDASSESSMENT
LaboratoryInvestigation
No Test
1
2
3
4
5
6
7
8
9

HB
HCT
WBC
PLT
PMN
Lympho
Mono
Eos
Baso

Result
11,3
34
9700
457K
82,3
23
9,4
4,6
0,7

Medication
1. Morphine0,1mg
2. Tramal50Mg.IVPRN4hr.
3. Onsia8mg.IVPRN6hr.

Normal
Men:1418gr/dl
Men:4048%

2035%
28%
14%
01%

interpretatio
n
Anemia

DATAANALYZE

No.
1

Data

Etiology
SurgicalWound

SD:

Problem
Acute Pain related

Thepatientsaidthathefeels

to surgical wound

painiftrytolifthisfoot(left

infection

side).
Patientsaidthathaspainon

Contaminated
Bacteria

theleftlowerextremitywith:
P: surgical wound,
fracture.
Q:Stabbing
R:onleftfoot
S:6(ModeratePain)
T: when moving and

woundcare

Definition:
Acute pain is
sensory

Inflamation

and

emotional
experiences which
are not interesting

Pain

thatappearbecause
of actual or
potential tissue

OD:

Blood pressure is 102/52

damaging and the

mmHg, Pulse is 80

timeis less than6

times/minute,Respirationrate

months.

is

20

times/minute,

Temperatureis37,8C.
Thepatientlooksnotrelax
The patient looks grimacing
inpain

SD:

Accident/over

Integrity of skin

Patientsaidthatthewoundon

pressuretotheOs.
Tibiadirectly

hisleftfoot
Thedocumentationexplained
that the patient has fracture
and occur vascular injury in
histibia(leftside)

disorder related to
theopenfracture
Definition:

OpenFractureand

Integrity skin of

vascularinjury

disorderisdisorder
of

OD:

dermis,

epidermisandbody

Patienthassurgicalwoundon

hisleftfoot.
Thenursesaidthatthepatient
skininwoundarealooksred

Inflamation

structureinvasy.

Pain

and the surgical wound has

infection
The patients wound looks
bandaged.
WoundAssessment
T =Tissuenonviable
I = Infection and/or
inflammation,
M
=

Moisture

imbalance
E = nonadvancing

or

undermined
3

SD:

SurgicalWound

Infectionrelatedto

The patient said that he has

infected

microorganism

gonethroughtwosurgeries
Hesaidthathiswoundonthe

leftfoot.
Thedocumentationexplained

Contaminated

histibia(leftside).
The patient said that feels
paininhissurgicalwound.

of

pathogenic.

Bacteria
Definition:

that the patient has fracture

and occur vascular injury in

Infection
Infection

infected

microorganism
pathogenic

is
of

OD:

Thenursesaidthatthepatient
skininwoundarealooksred
and the surgical wound has

infection.
Temperatureis37,8C.
Hb:11,3

SD:

The patient said that he is

onlybedrest.
Thepatientsaidthathefeels
painiftrytolifthisfoot(left

want to go to the toilet, to

vascularinjury

to vascular injury,
destructionofbone
tissue

Surgicalprocedure
Definition:
Immobility
Physicallimitation

mother

for

urinary

elimination.
OD:
Thepatientlooksbedrest.
The patient looks not relax
causeofhispain.

independently
Immobility

is

limitation physic
mobility

mobilityandambulate.
The patient said that go to
toilet is accompanied his

Immobility related

side).
The patient eats byhim self
andusesassistivedeviceifhe

TheopenFracture,

Fewofinformation

SD:

Thepatientsaidthatdoesnot

Aboutpatients

knowledge about vascular

disease

Patient and family

knowledge
deficiency related
to

injuryanditscomplication.

few

of

information
Knowledge

OD:

The patient and care giver

deficiency

Definition:

lookconfusewhenthenurse

Knowledge

asktodiscussaboutpatients

deficiency

disease.

is

information

which associated
withthedisease
NURSINGDIAGNOSE
1.
2.
3.
4.
5.

AcutePainrelatedtosurgicalwoundinfection
Integrityofskindisorderrelatedtotheopenfracture
Infectionrelatedtoinfectedofmicroorganismpathogenic.
Immobilityrelatedtovascularinjury,destructionofbonetissue
Patientandfamilyknowledgedeficiencyrelatedtofewofinformation

NURSINGONTERVENTION
No.
1

Nursingdiagnose

Purposeandresultscriteria

Acute Pain related to NOC

surgical

wound Paincontrol
infection
Withresultscriteria:

Nursing
intervention
NIC
1. Teach patient
hoetodopain

SD:
SD:
The patient said Patientsaidthepainless
thathefeelspainif
(Scale13)and/nopain
try to lift his foot
(leftside).
Patient said that he can
Patient said that
doespainmanagement
haspainontheleft
lower extremity OD:
with:
Patientlooksrelax
P: surgical Patientlookssmile
wound,
fracture.
Q:Stabbing
R: on left
foot
S:

6
(Moderate
Pain)
T: when
moving and
woundcare

2.
3.
4.

5.

management
non
pharmacology,
such

as
listening the
music,
sleeping, and
talking with
others
Identify cause
ofpain
Identify when
thepain
Solve the
causes that
increase the
pain
Collaboration
to

give
analgesic

OD:
Blood pressure is
102/52 mmHg,
Pulse is 80
times/minute,
Respiration rate is
20 times/minute,
Temperature is
37,8C.
The patient looks
notrelax
The patient looks
grimacinginpain
2

Integrity of skin NOC

NIC
disorder related to the Tissue skin and mucous 1. Wound care
openfracture
membraneintegrity
effectively
2. Monitorofthe
Withresultscriteria:
wound and
SD:
skin
Patientsaidthat SD:
3. Monitor

OD:

the wound on Patient said that the

hisleftfoot
wound has already
The
4.
healing
documentation
explained that OD:
the patient has Thewoundonpatientleft
fracture and
foot is not infection and
occur vascular
inprocesstobehealing
injury in his
tibia(leftside)

patient
nutritionstatus
Monitor sign
ofinfectionon
wound

Patient has
surgical wound
onhisleftfoot.
The nurse said
that the patient
skin in wound
area looks red
andthesurgical
wound has
infection
The patients
wound looks
bandaged.
Wound
Assessment
T
= Tissue
nonviable
I
=
Infection and/or
inflammation,
M
=
Moisture
imbalance
E
= non
advancing or
undermined

Infection related to NOC

infected

of Immunestatus
microorganism
Knowledge:infectioncontrol
pathogenic.
Withresultscriteria:

NIC
1. Monitor signs
of infection
fromwound

SD:
SD:
The patient said that the
The patient said
feelsgoodandnofever
that he has gone
through two OD:
surgeries
The wound is not
He said that his
infection
wound on the left Hbisaround1418gr/dl.
Temperatureisnormal
foot.
Thedocumentation
explained that the
patienthasfracture
andoccurvascular
injury in his tibia
(leftside).
The patient said
that feels pain in
his

surgical
wound.
OD:
Thenursesaidthat
the patient skin in
wound area looks
red and the
surgicalwoundhas
infection.
Temperature is
37,8C.
Hb:11,3

2. Collaboration
to

give
antibiotic
powder to
wound
3. Do infection
controlsuchas
sterilization
technique,
wash hand
before and
after contact
withpatient
4. MonitorWBC
5. Collaboration
for giving
antibiotic
6. Collaboration
togivevitamin
for
hemoglobin
7. Monitor hb
score

NOC
NIC
Jointmovementmobilitylevel 1. Discusstogive
SelfcareADLs
tools
ambulatory to
Withresultscriteria:
thepatient
2. Teach patient
SD:
SD:
how

to
The patient said The patient said that he
ambulatory
thatheisonlybed
candoactivityandmove
technique
rest.
byhimself
Immobility related to
vascular

injury,
destruction of bone
tissue

The patient said

thathefeelspainif OD:
try to lift his foot Mobilitylevelislessthan
(leftside).
10score
Thepatienteatsby Patient look mobile by
him self and uses
himself
assistive device if
he want to go to
the toilet, to
mobility and
ambulate.
The patient said
that gototoilet is
accompanied his
mother for urinary
elimination.

OD:
The patient looks
bedrest.
The patient looks
not relax cause of
hispain.
Patient and family Knowledge:disease
knowledge deficiency Knowledge:healthbehavior
related to few of Withresultscriteria:
information
SD:
The patient said
that does not
knowledge about
vascularinjuryand
itscomplication.

3. Identifypatient
ability to do
mobilization
4. Collaboration
to do physical
therapy
5. Identify and
monitor of
mobilitylevel

1. Teach patient
and family
about patients
disease
2.
Teach patient
DS
and family
Thecaregiversaidthat
how to do
sheunderstandabout
wound care to
diabetesandhowto
thepatient
preventit
3. Do discussion
about the
The care giver said that
disease and
shecandowoundcareif
how to care
thepatientgoeshome
about the
The patient said that he
disease
understand about his
disease.

OD:
The patient and
care giver look
confuse when the
nurse ask to
discuss about OD:
Thepatientandcaregiver
patientsdisease.

lookcooperativeandcan
answer the nurse
questions about fracture
andvascularinjury.