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1. Questions/Concerns/ Patient Understanding

1.1. Ability to participate in care management

1.2. Adresses questions to Nurse

1.3. Can repeat instructions back to nurse with understanding and rationale

2. Nursing Management

2.1. Medication Administration

2.1.1. Pain Management/Control IV infusion - Morphine/ Dilaudid acetaminophen, hydromorphone and morphine

2.1.2. Insert Peripheral IV Large Bore IV @ TKVO - Potential Fluid Resuscitation (NS/RL) Start infusion of NS or RL; according to hospital policy.

2.1.3. Prophylaxisis antibiotics cefazolin fights against gram +/- bacteria vancomycin gram + cocci and bacilli ex. Staphylococcus aureus piperciillin gram - organisms ex. Pseudomonas aeruginosa

2.2. Safety measures

2.2.1. Patient Id: DOB, Full Name

2.2.2. RCP/Hand hygiene

2.2.3. Oxygen and Suction Equipment Ready

2.2.4. Obtain Informed Consent

2.3. Comfort Measures

2.3.1. Orientation Assessment

2.3.2. Remove any clothing around injury

2.3.3. Provide warm blanket: prevent hypothermia

2.3.4. Emesis bin at bedside

2.4. Wound Care

2.4.1. clean external wound edges with NS

2.4.2. Low pressure irrigation PREVENT mobilization of nail

2.4.3. Immobilize wound surface with gauze/sertile pads

2.5. Documentation

2.5.1. Medication Antibiotic Therapy: Dose, duration & indication PRN medications

2.5.2. Wound care location, type, wound edges, drainage, odor etc.

2.6. Blood Specimen Collection



3.1. Differential Diagnoses

3.1.1. Liver Puncture Comprehensive Metabolic Panel LFT (ALT/AST/ALP) Bilirubin Albumin

3.1.2. Stomach Puncture CT/Ultrasound

3.1.3. Intestinal Puncture CT/Ultrasound

3.1.4. Peritoneal Puncture CT/Ultrasound

3.2. CBC/Electrolytes/Creatinine

3.2.1. INR, PT, aPTT


4.1. Pharmacological Management

4.1.1. Antibiotics

4.2. Surgical Intervention

4.2.1. Procedure

4.2.2. Complications Hemorrhage Infection

4.3. Interprofessional Collaboration

4.3.1. Surgeon Perform surgery to repair damaged structures or to remove foreign objects

4.3.2. Physician/Nurse Practitioner Prescribe medications Request blood work Request diagnostic testing

4.3.3. Nurse Perform a trauma assessment Assess the patient for complications (eg. infection) Obtain medical history Obtain vital signs

4.3.4. Radiology Technologist Perform diagnostic imaging Eg. CT scan, ultrasound, and abdominal X-ray to assess injury

4.3.5. Social Worker Provide support through the rehabilitation process Help patient cope with physical changes Assist the patient to maximize independence and autonomy in the various areas of his functioning

4.3.6. Nutritionist/Dietician Assess patient for ability to tolerate regular feedings Prescribe parenteral or enteral nutrition if needed due to trauma

4.3.7. Pharmacist Check and dispense prescribed medications

4.3.8. Physiotherapist Assist with early immobilization and breathing exercises


5.1. Discharge Planning

5.1.1. Patient Teaching Medication Administration Analgesic Stool Softeners Blood Thinners Past Medications Antibiotics Post-op Complication Prevention Wound care/Infection Management Signs and Symptoms of Infection Excess bleeding

5.1.2. Support Systems Family Friends Support Animal

5.1.3. Follow up Consultation Lab Draws PTT/PT/INR CBC Suture Removal Imaging

5.1.4. Medical Record/Procedural Review Patient Information Procedure Debrief


6.1. Patient History

6.1.1. Past Medical History Superficial cuts Hypertension (HTN) Overweight No history of falls High Stress

6.1.2. Demographics White 54 y/o man Construction worker Family Financial Provider Lives in a very safe and affluent neighbourhood Part of a westernized culture, born and raised in Canada

6.1.3. Medication History Daily Medications Beta Blockers (for management of HTN) Allergic Rx to past medications N/A Medications taken prior to admission N/A Vaccination History Tetanus Booster = UP TO DATE Annual Flu vaccine

6.2. Objective Assessment

6.2.1. CHIEF COMPLAINT Puncture wound to epigastric area 1-inch, galvanized nail from pneumatic nail gun in epigastric area visible under xyphoid process A + O x3, diaphoretic, pale Localized swelling, rednessness at injury site

6.2.2. Vital Signs Temperature: 37.2 HR: 90 BPM RR: 20 BPM BP: 165/98 mmHg O2 Sat: 96% on RA

6.2.3. BMI: 25.0

6.3. Subjective Assessment

6.3.1. Clinical Manifestations Pale and slightly diaphoretic Alert and conversing Sharp pain of 2/10, not radiating to other areas PQRSTU?

6.4. Continous Monitoring

6.4.1. Neurological Assessment Mental Status: A+OX3 Clear Speech

6.4.2. Airway, Breathing, Circulation Continuous Vital Signs Skin Colour: appropriate for ethnic background Temprature: Warm to touch

6.4.3. Pain Intensity

6.4.4. Abdominal Assessment Inspection: masses, colour changes, swelling, enlarged viewns Auscultationg Bowel sounds ,percuss for general tympany, liver span, and splenic dullness.