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Medical Diagnoses:Acute Pain related to injury of finger, Impaired skin integrity, Anxiety and Risk for infection


1.  Acute Pain related to injury of finger and thumb.

 

·         Evidenced by pain upon movement

·         Reported by patient

·         Grimacing of patient

2.  Impaired skin integrity related to injury of index finger and thumb.

 

·         Surgical incisions to repair injury

·         Lacerations

2.  Impaired skin integrity related to injury of index finger and thumb.

 

·         Surgical incisions to repair injury

·         Lacerations

4.  Sleep deprivation related to injury and q 1 hr monitor of injury.

 

·         Patient states not sleeping.

·         Patient uncomfortable and in pain.

·         Leech therapy q 3 hrs and temp monitor q 1 hr.

39 Male Caucasian 5’11” 170 lbs

BP 127/73  HR 78  RR 16  99% O2 RA

Temp 97.0 oral  Full Code Reg Diet

No Caffeine or Chocolate

Hx:  Smoker not been to MD in 20+ yrs

NKA 

Chief Complaint: Lost index finger and thumb in press machine at work

Admit Dx:  Reattachment R index finger and R thumb

Pain scale ranges from 1-5 on pain scale of 10, digit temp checks q 1 hr, Leech therapy q 3 hr

5.  Anxiety related to amputation/reattachment of finger and thumb.

 

·         Patient is from another state.  He is away from family.

·         Income is reduced to 66% while off work, has 3 children.

·         Does not look like finger is going to heal, he is worried about career future.

6.  Impaired physical mobility related to injury of dominant hand.

 

·         Amputation/reattachment of R index finger and R thumb.

·         Pain in hand.

·         Unable to use hand and will be in rehab for several months.

7.  Bathing/Hygiene Self Care deficit related to injury of dominant hand.

 

·         Amputation/reattachment of index finger and thumb.

·         Unable to bathe himself or wash hair and this will be a problem for several weeks while injury is healing.

8.  Risk for infection related to incisions and laceration from hand injury.

 

·         Amputation/reattachment of index finger and thumb.

·         Must keep some incisions open for Leech therapy q 3hr.

·         Tissue destruction from injury.


NANDA Diagnostic Statement: Acute pain related to crushing and amputation injury of R index finger and R thumb AEB patient statements and observations of patient, such as guarding and grimacing.

 

Behavioral Outcome / Goal:  Patient to be bathed and maintain patient comfort and keep pain below a 4 on 1-10 pain scale during 8 hour shift.

 


Nursing Interventions:

 

 

·         Assess pain severity on scale of 1-10 every hour by asking patient.

 

·         Monitor vital signs

 

 

·         Provide medications per physician order

 

 

·         Keep hand elevated and wrapped in heat blanket to control digit temp and improve circulation.

·         Watch patient for signs of elevated pain or discomfort.

·         Bathe patient and provide linen change in order to encourage rest and provide comfort.

Rationale:

 

 

·         Initial assessment provides baseline & comparison.

 

·         Usually altered in acute pain.

 

 

·         Meds will help alleviate pain and provide comfort.

 

·         Elevation will help with swelling and provides pain relief.

 

·         How a patient sits, holds body or facial expression can reveal a lot about how a patient feels.

 

·         Bathing can help pain mgt and provide relaxation.

Client Response:

 

·         Patient fluctuates between 1-5 on pain scale.

 

·         BP 127/73  HR  78  RR  16      Temp 97.0 oral  99% O2 on RA

 

·         After medication patient is a 1-2 on pain scale.

 

·         Patient states hand feels much better when elevated and stable on pillow.

 

·         Patient grimaces during dressing changes and exams by doctor but never complains but wants to be left alone afterwards to rest.

 

·         Gave as thorough a bath as possible and was able to wash his hair and he actually fell asleep after.

Summarize impressions of client progress toward outcomes / problem resolution:  Patient is very pleasant and cooperative despite being away from all family and friends during this ordeal.  I am concerned with depression and anxiety as he is desperate to return home and is extremely concerned about reduced income.  We discussed possibility of him returning to work and performing office duties and he is going to discuss with his boss and the work comp rep.  The doctors are still concerned about the index finger, however it looked better to me after 2 rounds of leech therapy; it bled well and did not appear as dusky in appearance.  I was able to get him to the shower head to wash is hair and his legs and back and he said that he felt like a new man and fell asleep for a while. 


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