N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide • Note: Always provide first-aid care to open wounds prior to a full nursing assessment • Perform a primary survey. This includes a “rapid assessment” to identify life threatening injuries and perform emergency resuscitation if needed. Assess ABCs and vital signs; watch for signs of shock (hypotension or tachycardia). • Check for heavy bleeding and arterial/venous compromise • Inquire about the details of the injury: how injury occurred, where, when, and who was involved • Ask the patient about recent tetanus vaccinations: length of time since lastbooster • Assess wound and note the size, location, and amount of bleeding, if any • Neurological checks to affected area; peripheral pulses, sensations, and range of motion • Evaluate laboratory and radiology reports: o X-ray: Determines depth of injury o CBC: Can check for blood loss o Culture of wound: Checks for presence of organisms in the wound Nursing diagnosis for soft tissue trauma: • Pain related to soft tissue trauma and injury • Altered peripheral tissue perfusion related to blood loss, secondary to soft tissue injury • Risk for infection related to a break in skin integrity • Impaired skin integrity related to a break in skin Nursing interventions for soft tissue trauma: • Give appropriate first-aid care: pressure to bleeding, cleanse wounds, bandage, and avoid use of tourniquet unless ordered by MD for amputations • Monitor and assess for shock • Give IV fluids if necessary; blood transfusions per MDorder • Assess for pain with pain scale of 1 to 10 using verbal scale or faces scale • Give pain medications per MD order • Apply splints or other immobilization techniques • Prepare patient forreconstructive surgery to restore function and appearance to the injured body part • Check peripheral pulses to extremities, check skin color, and check temperature frequently • Change dressings on a regular schedule to prevent infection, drainage, and bleeding • Assess open wounds with each dressing change for drainage, bleeding, redness, and odor • Give antibiotics per MD order; encourage patient to finish full prescription even if there is not an infection present • Give tetanus booster if needed ©2017 Achieve Test Prep Page 142 of 204