Major Multiple Trauma

Major Multiple Trauma

1. Assessment

   • Patient appear weak and has SOB after completing a small task like turning and repositioning.  Use of  accessory muscle for respiration was assessed. Patient report of pain level of 8 on a 1-10 pain scale. Patient has Lidocaine patch that is placed in between incisions. Patient RH was flacid and edematous and LH has very little movement along the phalanges. Patient has 2 sutures in the upper left side of the thoracic region. .
   • Pain
   • Weak
   • SOB

2. Diagnosis

   • Acute Pain may be related to disruption of skin, tissue muscle integrity, musculoskeletal or bone trauma, possibly evidenced by report of pain level of 8 on 1-10 scale by the patient. Ineffective breathing pattern may be related to decreased lung expansion as evidenced by changes in respiratory rate and depth. Impaired skin tissue integrity. Maybe related to broken skin, traumatized tissues, invasive procedures possibly evidenced by disrruption of skin surface layers and tissues.
   • Acute pain r/t disruption of skin and tissue muscle integrity
   • Ineffective breathing pattern r/t decreased lung expansion
   • Impaired skin tissue integrity r/t broken skin and traumatized tissues

3. Planning(Pt. goals and expected outcome)

   • Patient pain will be relieved or controlled. Patient will verbalized a pain level of 3 on 1-10 pain scale. Lidocaine Patch will be changed  every 12 hours according to orders.Patient will be informed that it is his responsibility for reporting pain and relief of pain completely.  Patient will appear relaxed and able to rest and sleep appropriately. Patient will establish effective respiratory pattern free of cyanosis or other signs of hypoxia. Patient shortness of breath will be diminished during activity. Patient will achieve timely wound healing before discharge.
   • Pt. will verbalized a pain level of 3 on a 1-10 pain scale.
   • Pt. Lidocaine patch will be changed Q12hr.
   • Pt. will achive timely wound healing before discharge.
   • Pt. SOB will be diminished during activity

4. Intervention

   • Monitor patient airway, auscultate breath sound. Listen to gurgling, wheezing, crackles, observe respiratory rate and depth, chest expansion, skin color and airflow. Provide pain meds as ordered. Evaluate pain frequency. Emphasize patient responsibility for reporting pain and relief of pain completely. Access vital signs.Access other causes of possible discomfort other than operative procedures. Provide additional comfort measures like back rubs, heat or cold applications.Encourage use of relaxation techniques such as deep breathing exercises, guided imagery, visualization or music.. Provide regular  oral care. Document effectiveness or adverse effect of analgesia. Examine skin for breaks or irritation and signs of infection like redness around the sutures. Check if the area is warm and tender to touch. Inspect incision regularly, noting characteristics and integrity. Splint incision or area with pillow or pad during coughing and movement. Gently reposition the RA before turning or when proping up the patient in bed. Let patient know it is important to request medication before pain becomes severe.
   • Monitor pt. airway, auscutate breath sound.
   • Observe respiratory rate and depth
   • Provide pain meds. as ordered.
   • Emphasize pt.responsibility for reporting pain and relief of pain.
   • Examine skin for signs of infection like redness around sutures

5. Evaluation.

   • Patient established effective respiratory pattern. Patient airway clear of wheezing or any abnormalities. Free of signs of cyanosis or other signs of hypoxia. Respiratory rate and depth within normal limits, no chest expansion. Vital sign normal and patient is afebrile. Patient shortness of breath diminished during activity. Patient verbalized  pain level of 3 on 1-10 pain scale. Lidocaine patch changed after 12 hours. Patient verbalized understanding that he is responsible for reporting pain and relief of pain. Patient skin free of breaks, irritation or any signs of infection like redness around the sutures. The suture area is nontender and not warm to touch. Pillow used for splinting during coughing and movement . Right arm was gently reposition before turnning. Medication was given before all activities. Patient relaxed and verbalized satisfaction with care.
   • Pt. established effective respiratory pattern, airway clear of wheezing.
   • SOB diminished during activity
   • Pt. verbalized pain level of 3 on a 1- 10 pain scale.