Exploratory Laparotomy of a Penetrating Chest and Abdominal Wound

A Nursing Case Study Presented to the Faculty of College of Nursing

of the University of St. La Salle College of Nursing
Bacolod City

In Partial Fulfillment of the Requirements in

NCM 112 - Related Learning Experience

Submitted by:
Alcala, CJ Louise G.
Aplaon, Aidel Feb V.
Artillo, Aljean Altheo L.
Bañares, Marynelle A.
Barnacha, Hasmin Francesca L.
Barroa, Kheahna Faith P.
Bito-on, Bryle James B.
Bolivar, Jay Tom A.
Bravo, Maria Christina Gabriela L.
Concha, Arianna Beatrice V.
BN3B - Group 1

October 2021
 Table of Contents

Page
I. Introduction 3
II. Objectives 3
a. Patient-Centered Objectives 3
b. Nurse-Centered Objectives 4
III. Anatomy and Physiology 4
IV. Definition of Terms 10
V. Baseline Data 11
VI. Nursing History (Gordon’s Functional Patterns) 11
VII. Health History 17
VIII. Cephalocaudal Assessment 18
IX. Laboratory Results and Diagnostic Tests 20
X. Pathophysiology 22
XI. Nursing Care Plans 23
XII. Drug Studies 39
XIII. Health Teaching 50
XIV. Conclusion and Recommendations 59
XV. References 60

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 I. Introduction

Exploratory laparotomy is a surgical procedure done in order to identify the causes of problems
such as abdominal pain or bleeding that testing is not able to diagnose. This procedure is also utilized for
abdominal injuries that call for emergency medical care. This surgery uses an incision in the belly area in
order for the surgeon to inspect and check the organs inside the abdomen. If the cause of the problem is
found during this procedure, treatment often follows and is done at the same time.

The top five leading causes of death due to injury in the Philippines, for all ages, are assault,
transport accidents, accidental drowning and submersion, intentional self-harm, and accidental falls.
According to the World Health Organization Report in 2009, it revealed that road crashes, suicide, and
violence were among the main causes of death worldwide for people aged 10 to 24 years. In 2011 (WHO
Report), injuries were reported to be responsible for 9% of all deaths with road traffic injuries claiming
nearly 3,500 lives each day, making it among the 10 leading causes of mortality globally. The Online
National Electronic Injury Surveillance System (ONEISS) Fact Sheet for 2010-2012 revealed that transport
or vehicular crash was the leading cause of unintentional injuries and interpersonal violence
(mauling/assault, contact with sharp objects, and gunshot) was the leading cause of intentional injuries.

Stab wounds are a form of penetrating trauma that may be self-inflicted or inflicted by another
person either accidentally or intentionally. They may be caused by a variety of objects and may occur
anywhere in the body.

The patient, Rommel Claridad experienced assault leading to injury via stab wound. The night of
the incident the patient was reportedly drinking with his friends outside a sari-sari store. The patient
spoke with his neighbor which was the wife of the assailant after which when their conversation ended
the assailant which was also intoxicated got a cane knife and proceeded to stab Rommel. Rommel was
rushed to the hospital accompanied by his friend who then went on to go to the police station to file a
blotter report.

Add last paragraph why you decided to use this case for your case study

II. Objectives
Patient-Centered Learning Objectives

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General Objective: After 4 days of clinical exposure, the patient will gain understanding on penetrating
trauma, current condition, possible risks, and complications, to achieve optimal wellness.

After 8 hours of clinical exposure, the patient must be able to:

A. Achieve proper hygiene and sanitation practices to avoid infections.

B. Verbalize the importance of adequate management to promote skin integrity.
C. Describe various treatments or procedures that aid in recovery.
D. Reduce the reoccurrence of penetrating trauma by observing different cues and acknowledging
preventive measures.
E. Understand the importance of medication compliance and proper treatment to achieve optimal
wellness.
F. Demonstrate a positive response to the interventions that the nurse is implementing.

Nurse-Centered Learning Objectives

General Objective: After 4 days of clinical exposure, the student nurse will be able to identify and
determine patient’s general health status and the need of patient undergoing Exploratory Laparotomy
by applying appropriate nursing intervention utilizing the nursing process.

After 8 hours of clinical exposure, the student nurse must be able to:

● Apply appropriate interventions on how to properly take care of a patient with chest stab
wounds.
● Construct nursing diagnoses appropriate for clients with chest stab wounds to address priority
concerns during planning and interventions.
● Describe the impact of injury to the skin and the process of wound healing.
● Identify safety measures when taking care of the client with chest stab wounds post-operably.
● Predict risks for infections or complications after exploratory laparotomy.
Objective should have the skills, knowledge and attitude. Each item should be represented like in
ATTITUDE example Enhance confidence in handling patients with the same health condition.
SKILLS – example construct, assess, demonstrate, and etc

III. Anatomy and Physiology

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A. Respiratory System
Our body systems work tirelessly to sustain our bodies. For our bodies to maintain
homeostasis and proper functions, these systems must co-function to produce a sufficient
amount of energy. One of the key players in producing energy is our respiratory system. It
allows for the process of oxidation to take place, whereby food molecules are combined with
oxygen, resulting in the production of carbon dioxide and water. This lets our body expel carbon
dioxide from our circulatory system and allows for the absorption of oxygen from the
atmosphere at rates that are proportional to the needs of our bodies. The respiratory system
allows for this process to take place, oxygen entering our bodies in exchange for the elimination
of carbon dioxide through respiration.
The respiratory system begins from the nose and mouth, pharynx, trachea, bronchi,
bronchioles, lungs, and down to the diaphragm.

Nose and Mouth

Openings that are
ciliated and lined by mucosa
respectively, pulling air into
our bodies and down our
respiratory system.
Pharynx
More commonly
known as our throat, it is a tube that delivers air from our nose and mouth down to our
windpipe (trachea).
Larynx
Also known as our “voice box”, it is essential in phonation, protects the lower
respiratory tract from foreign bodies, and facilitates respiration.
Trachea
More commonly known as our windpipe, it is the passage that connects our throat and the
lungs.
Bronchial Tubes
Tubes that can be found at the end of the trachea, which connects the upper respiratory
tract to the lungs.

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 Lungs
A two-part organ, the left, and right lung, each consisting of two (2) and three (3) lobes
and are responsible for the exchange of gases. The exchange of gases takes place at a
microscopic level and happens in the air sacs of the lungs (alveoli). The absorbed oxygen is then
distributed into the blood by way of the pulmonary circulation.
Diaphragm
Located directly under the lungs, it plays a major function in respiration. It continually
contracts, mostly involuntarily. Upon inhalation, it flattens and allows air to enter the
respiratory cavity. Upon expiration, it expands to let the air out of the lungs.
B. Gastrointestinal System
Another key player in keeping
our bodies alive and well is the
gastrointestinal system. The organs in
this system are responsible for receiving
food, breaking it down to absorbable
particles, absorbing the nutrients into the
bloodstream, and eliminating indigestible
materials by way of excrement. This
system is composed of the mouth,
throat, esophagus, stomach, small
intestines, large intestines, pancreas,
liver, gallbladder, rectum, and anus.
Mouth
This organ is the entryway for both the respiratory and gastrointestinal systems. It is
lined with mucous membranes, where the first stage of physically breaking down food occurs
through the process called mastication, along with a digestive enzyme called amylase.
Pharynx
This organ, known more commonly as the throat, lies behind and below the mouth.
When food and fluids leave the mouth, they pass through the throat. Swallowing of food and
fluids begins voluntarily and continues automatically. A small muscular flap (epiglottis) closes to
prevent food and fluids from going down the windpipe (trachea) toward the lungs.
Esophagus

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 It is a thin-walled, muscular channel lined with mucous membranes that connect the
throat with the stomach. Food and fluids are propelled through the esophagus not only by
gravity but also by waves of rhythmic muscular contractions called peristalsis.
Stomach
This organ serves as a temporary storage for food, as well as the location of the
beginning stages of digestion and mixing of food with enzymes to make it even more digestible.

Small Intestine
This organ also breaks down food and absorbs the nutrients derived from the broken
down food. After the food is processed in the small intestine, the food is passed down into the
large intestine.
Large Intestine
After the food is passed down into this organ, it extracts the water from the food and
distributes it throughout the body. The remaining material is then passed down into the colon
and is stored as fecal matter.
Liver
This organ serves as the chemical factory of the body while regulating the chemical
levels of the body systems. This is where most of our lipids are broken down and are converted
into energy.
Pancreas
Our pancreas is responsible for the production of digestive enzymes, which are
instrumental in the digestion of fats, starches, and sugars.
Gallbladder
It is a muscular storage sac for bile until it is needed for digestion. When we consume
food, it contracts and extracts bile into our digestive system.
Rectum
It receives stool from the colon and alerts the brain, the cerebrum specifically, the need
for defecation or evacuation of the contents.
Anus

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 It is the end of the gastrointestinal tract and is responsible for pushing out stool from
the body.
C. Relationship of the Respiratory and Digestive System
Digestive Dependence Upon Respiration
The digestive tract is dependent upon the respiratory system because your digestive tract
functions by using muscular contractions to break up food and move it along the tract. Smooth
muscle in the stomach churns food into a liquid, and contractions of the intestine move food
through the system. These muscles depend upon oxygen in order to function -- without oxygen,
your digestive tract would stop working.

Respiratory Dependence Upon Digestion

Similarly, your respiratory tract wouldn't be able to function without the products of digestion.
While the process of exhalation is passive and doesn't require muscular contraction, you
contract the respiratory muscles -- including the diaphragm and intercostal muscles -- to inhale.
Muscles need fuel in order to contract, and the fuel they use is primarily in the form of
carbohydrates and fat. The efforts of the digestive tract provide the cells of the respiratory
muscles with fuel.
Cellular Dependence Upon Both Systems
The body cells depend upon products of both the respiratory and digestive systems' functions in
order to maintain themselves. To produce energy, cells burn nutrient molecule fuel in oxygen.
The digestive tract provides the nutrient molecules, through the process of digestion, while the
respiratory tract provides oxygen. As such, the two systems work together to give your cells the
ingredients they need to produce energy, which they use to communicate, build cellular
products and grow.
D. Integumentary System

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The integumentary system is the largest organ of the body that forms a physical barrier between
the external environment
and the internal environment
that it serves to protect and
maintain. In addition to its
barrier function, this system
performs many intricate
functions such as body
temperature regulation, cell
fluid maintenance, synthesis
of Vitamin D, and detection
of stimuli. The various
components of this system work in conjunction to carry out these functions—for example, body
temperature regulation occurs through thermoreceptors that lead to the adjustment of
peripheral blood flow, degree of perspiration, and body hair.

Components of the Integumentary System

Skin: The skin is made up of two layers—the superficial epidermis and the deeper dermis.
The epidermis is the tough outer layer that acts as the first line of defense against the external
environment. It is composed of stratified squamous epithelial cells that further break down into
four to five layers. From superficial to deep, the primary layers are the stratum corneum,
stratum granulosum, stratum spinosum, and stratum basale. In the palms and soles, where the
skin is thicker, there is an additional layer of skin between the stratum corneum and stratum
granulosum called the stratum lucidum. The epidermis regenerates from stem cells located in
the basal layer that grow up towards the corneum. The epidermis itself is devoid of blood supply
and derives its nutrition from the underlying dermis.

The dermis is the underlying connective tissue framework that supports the epidermis. It further
subdivides into two layers—the superficial papillary dermis and the deep reticular layer. The
papillary layer forms finger-like projections into the epidermis, known as dermal papillae, and
consists of highly vascularized, loose connective tissue. The reticular layer has dense connective
tissue that forms a strong network. The dermis as a whole contains blood and lymph vessels,

9
nerves, sweat glands, hair follicles, and various other structures embedded within the
connective tissue.

Hypodermis:The hypodermis lies between the dermis and underlying organs. It is commonly
referred to as subcutaneous tissue and is composed of loose areolar tissue and adipose tissue.
This layer provides additional cushion and insulation through its fat storage function and
connects the skin to underlying structures such as muscle.

Hair:Hair is derived from the epidermis but grows its roots deep into the dermis. Its structure
divides into the externally visible hair shaft and the hair follicle within the skin. The hair follicle
has an intricate structure that contains the hair bulb that actively divides to extend the hair shaft
vertically. It serves as mechanical protection for the skin, increases sensory function, and aids in
regulating body temperature. Arrector pili muscles located in the dermis attach to hair follicles,
helping the shaft to stand and trap air close to the epidermis for temperature control.

Nails:Nails form layers of keratin and appear at the dorsal tips of the fingers and toes. The nail
growth begins at the nail matrix that creates new cells and pushes old cells out distally. The
visible portion of the nail is the nail plate covering the nail bed, where it adheres to the finger.
Nails function to protect the fingers and toes while increasing the precision of movements and
enhancing sensation.

Associated Glands
Sudoriferous glands, also known as sweat glands, are further divided into eccrine and apocrine
glands. Eccrine glands are distributed throughout the body and primarily produce serous fluid to
regulate body temperature. Apocrine glands are present in the axilla and pubic area and
produce milky protein-rich sweat. These glands are responsible for odor as bacteria break down
the secreted organic substances.

Sebaceous glandsare part of the pilosebaceous unit, including the hair, hair follicle, and arrector
pili muscle. It secretes an oily substance called sebum, a mixture of lipids that forms a thin film
on the skin. This layer adds a protective layer, prevents fluid loss, and also plays an antimicrobial
role.

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IV. Definition of Terms
The following complicated terms or jargon are defined to facilitate comprehension of
the report:

Exploratory Laparotomy. This procedure is performed on patients that have unexplainable

abdominal pain or have sustained abdominal trauma, as in the current case. This is done for
therapeutic purposes, as well as to diagnose a condition.

Incision. It is a cut into the skin or other tissues by the use of a scalpel by a healthcare
professional.

Homeostasis. This is the maintenance of the internal environment by an organism. This is

disrupted when something has physiologically deviated in your body systems.

Strenuous. Requiring energy or using great effort.

Dehiscence. An event that is the result of a failed wound healing. This is the partial or total
separation of wound edges.
Evisceration. This event occurs when the organs are outside the body.

V. Baseline Data
Name: Rommel Claridad
Address: Pandanon, Murcia, Negros Occidental
Age: 47 years old
Sex: Male
Civil Status: Married
Date of Birth: January 22, 1974
Number of Siblings: N/A
Number of Dependents/Children: Two (2) daughters
Religion: Roman Catholic
Highest Educational Attainment: Grade 3
Occupation: Laborer "Karga Tapas"

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 Person next-to-kin: Wife and 2 daughters
Date of Admission: October 04, 2021 (2 am)
Date of Care: October 04, 2021 (8 am)
Attending Physician: Dr. Abueg
Medical Diagnosis: Stab wound 7th ICC, 8th ICC, Grade 1V liver injury,
Grade II Diaphragmatic injury, Grade II perforation stomach
Chief Complaints: Stab wound chest abdominal area
VI. Nursing History
Using Gordon's Functional Health Patterns Assessment, the student nurses assessed the nursing
history of the patient by covering the 11 subcomponents about the patient's different health systems.
These are the following: Health Perceptions and Health Management Patterns, nutritional-metabolic
patterns, elimination patterns, activity-exercise patterns, sleep-rest patterns, cognitive-perceptual
patterns, and self-perception--self-concept roles-relationship pattern, sexual-reproductive pattern,
coping-stress tolerance pattern, and values-beliefs pattern. The patient's response to each question was
collected and documented through an interview.
A. Health Perception and Health Management Pattern

The patient's general health is relatively stable. He verbalized having experienced common
illnesses like common cold, fevers, and cough but experienced nothing too serious. His opinion of health
is having a strong body capable of doing labor and activities of daily living with ease together with a diet
filled with nutritious foods recommended for a person's daily nutritional intake. Together with his
family, the patient actively participates in the immunization program of the health center. Although he
cannot recall his last immunization record, he verbalized that he and his family completed most of the
immunization against the seven targeted diseases. He has no allergy to food but experiences mild
allergic reactions when in contact with sugarcane and rice pollens only for a few minutes. In a year, he
verbalized having to experience recurrent common cold and cough but takes Rexidol and other over-
the-counter medications as his form of treatment. He added that he rests when tired, but his body can
handle these common illnesses most of the time. He claims he smokes ten sticks of cigarettes a day and
drinks alcohol occasionally to relax and rid himself of his fatigue. He rarely buys antibiotic medications as
he claims they are too expensive and only do so when needed. He is not under any maintenance
medications despite him being in a family with cardiovascular diseases. A few accidents have occurred in
his demographic location, but he has never been in one himself. The patient takes Enervon only when

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work becomes taxing for him to have the energy to keep on working. If they are financially unstable,
they do not purchase vitamins to save more money and make ends meet. He consults the doctor only
when he feels over-the-counter medications do not alleviate the signs and symptoms of this condition or
when he feels his condition does not improve as quickly as it usually does. There was no record of any
hospitalization nor surgical operations in the past as he is a relatively healthy person.

B. Nutrition/Metabolism Pattern

The patient's nutritional intake consists of mainly fish, pork, and vegetables, as he claims to have
an abundant source of fresh vegetables in his area. Although, he consumes eggs, dried fish, and sardines
when little to no work is available for him instead of fish and pork. He rarely buys fruits from the
marketplace as he claims it is too expensive, but he eats fruits available to him as natural food resources
in the area. He rarely drinks juice and soft drinks as he frequently drinks water, especially when working
hard in the fields to hydrate himself. He drinks whiskey four times a week together with friends to
unwind and relax, but he drinks more than he usually does when there are occasions and parties. He has
a great appetite for food and weighs about 70kgs with a height of 5'2. He feels he has gained more
weight but cannot specify the number of pounds since he does not weigh himself periodically. He does
not have any allergies when it comes to food and can eat anything he wants; he added that although
they have a family history of cardiovascular disease, his blood pressure is stable, so he eats everything in
moderation. He verbalized having numerous scratches and wounds, especially after working in the
fields but added that minor wounds and scratches often heal quickly with the help of guava leaves and
amoxicillin. After the wound heals, it usually leaves crusts or scabs, making the skin feel dry to the touch,
the patient added. Calluses on both the hands and feet commonly occur due to the hard labor at the
sugarcane or rice fields. His nail beds are white, and there is no presence of dandruff since he bathes
every day.

C. Elimination Pattern

The patient claimed his voiding pattern to be of standard frequency since he drinks plenty of
water each day, adding he pees a lot, around four times a day in large amounts, due to the number of
glasses of water he drinks after meals. The color of the urine is very light yellow, with no unwanted
odors and abnormal discharges noted. He added having to experience UTI and polyuria in the past due
to the excessive heat; the urine was of orange color. The patient has managed the condition well since

13
then, as it only occurred only this one time. He verbalized pooping normally and rarely experienced
constipation and difficulty when defecating. He usually defecates once a day and has never considered
using laxatives as he claims to have not experienced problems in defecating.

D. Activity/Exercise Pattern

The patient can perform all activities of daily living independently without feeling extreme
fatigue. The patient does not engage in other strenuous exercises since he considers walking to his
workplace and other locations rather than taking a pedicab or motorcycle and working at the fields as
his everyday exercise. If there are no sugarcanes or rice to harvest at the fields, he does carpentry at
home and rests during his free time. He verbalized drinking whiskey with his friends at night to pass the
time and unwind. He claims to have no respiratory difficulties experienced even when doing hard labor.

E. Cognition and Perception Pattern

The patient is well aware of his identity, current time, and location. He can answer questions
spontaneously since he is alert, awake, and well-oriented. He does not require the assistance of a
hearing aid since he is still able to perceive sounds clearly and audibly. The patient can see things and
people clearly, although he claims to have slightly blurry vision when reading but does not use glasses
since he finds it difficult or tiresome to wear glasses. There have been no changes in the patient's
memory as he can readily recall current and past events spontaneously. He is assertive and firm when
making a decision and claims to be the decision-maker in the family and only encounters difficulty when
money is involved but, in the end, could still make up his mind for the benefit of his family. He is open to
learning and trying new things and considers himself a fast learner, especially if it is within his line of
interest. He feels pain at the surgical site but tries to rest and sit still to minimize the throbbing
sensation in the area.

F. Sleep and Rest Pattern

The patient rests for six hours a night as he sleeps around 10:00 pm and wakes up at 4:00 am
because he still has to walk towards his workplace at the sugarcane and rice fields. He claims that he
does not experience sleep onset problems or nightmares that may disrupt his sleep or rest. He wakes up
feeling tired on some days, but he claims he feels energized on other days, especially if he's had a good
night's rest for more than six hours. He does not take any sleeping medications since a bottle or two of

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whiskey is enough to get him sleepy. After arriving from work, he no longer has the energy to exercise
and only drinks coffee or whiskey to help him sleep at night. There are times where he does not drink
whiskey but delays his sleep schedule by an hour; instead of sleeping at 10:00 pm, he tends to fall asleep
at around 11:00 pm. The patient also claims to have afternoon naps during work breaks to make up for
his sleep at night.

G. Self-Perception/Self Concept Pattern

The patient verbalized the changes that he noticed in his body that gave him problems, starting
when he was experiencing pain from his arthritis, on his feet and knees, where he goes to have them
massaged to ease the pain but will only last for a while then the pain will radiate once again. However,
even with this, he can still go to work every day. Another change that he perceived about his body
comes from the pain in his stab wound that is giving him breathing problems and can cause him pain
when moving. The thing that frequently irritates him is when his orders aren’t being followed
immediately. Although he’s fine getting along with others, he just cannot handle an argument without
getting angry, that is why he chooses to drink alcohol at home sometimes instead of outside with his
peers. In terms of emotions, he is not subject to losing hope because even though he is not that
financially stable in life, he is determined to get past this obstacle as long as he works hard in his job.
The patient’s self-perception about himself is that he stays grounded in his principles to just keep
working hard and do what he can and his obligations. He confirmed that he is happy with who he is now
physically and that he’s healthy, but still wished that if he had just finished his education, he could’ve
had an easier life.

H. Role Relationship Pattern

The patient has a family, with his wife and 2 kids. The main problem that he faces is a financial
one because his income is not enough sometimes for their family. That he can't afford to buy medicine
whenever one of them becomes sick, which can become the root of the fights that he can have with his
wife. Despite their circumstances, he's grateful that they haven't experienced a major illness in their
family. His relatives borrow money from him sometimes, that they're a member of the 4Ps, and that
they also receive support from the government. There are also others that borrow money from him that

15
becomes a source of extra income for them. Both of his kids are going to school, one just graduated high
school and the other is in 8th grade. That their eldest goes to work to help them in expenses as well.
Their family's first hospital admission is from what happened to him, but as they're members of the 4Ps,
their bill was given for free. Despite it being free, they do not wish for it to happen again. With their
children, disciplining them has not been a problem at all. Both of them being girls, and when being
scolded they follow immediately and are very helpful in their household. In terms of the patient's social
life, he has a group of friends with whom he's with whenever they go out for drinks. His mother and
sibling are both still around too. However, when he's facing a minor problem, he keeps it to himself and
doesn't like to share it. He chooses to be positive and happily drink away his problems. His work usually
goes well and goes home in the afternoon, where his children wait for him back home. That Sunday is
his day off and sometimes save from buying charcoal by chopping down some wood for cooking. In
participating in activities as members of the 4Ps, they help clean the barangay and school every month.
He loves basketball but doesn't have time to join and is not of age anymore to play. When he was
admitted to the hospital, his children were the ones helping his wife and mother in their home, because
he was unsure whether he'll stay even longer in the hospital. In their household, he and his wife are the
decision-makers but there are times that his wife knows more than him and he just assists her.

I. Sexuality and Reproduction

The Patient has no problem with his sexual life, and both he and his wife are happy. However,
he stated that it is not as often as when they were younger due to them being tired most of the time. His
wife occasionally takes birth control pills, to lessen their chances of adding another sibling for their
children. The last pregnancy of his wife was 13 years ago and still fertile, as she has not entered into
menopause yet, but they have no plans in having another child.

J. Coping/ Stress Tolerance

The Patient's usual manner when handling stress was getting help from his family members. The
big challenges that happened in his life were 10 years ago when his father died from unknown causes.
Relying on his family members and friends was his solution when dealing with big problems, especially
financial problems. According to the patient, he becomes tense when he’s dealing with lots of problems
and hardly grasps it but with the help of whiskey, which is his daily drink to pass time until he sleeps,
was a great partner when dealing with stress and tension. The patient has no involvement with any

16
illegal activities or drugs. He also had no maintenance since the patient had no known underlying
disease. If unexpected problems arise, he positively answers that he can find a solution by getting help
from his family members or friends if he really has no choice. But if he can solve it on his own, he’s not
bothering to get help from others, as long as he is able to handle the problem, he resolves it on his own.
According to the patient, not all the time he resolves the problem, it even takes years of sacrifices to
totally solve the problems but still manage to overcome them. He states that he needs to be strong
since he is the head of the family solving those problems was his own obligation. Usually, their problem
was really on financial aspects and the least he could do was to borrow money from his family or if not
available, from his friends.

K. Values and Belief Pattern

As stated by the patient, he wants to disembark from poverty with high hopes that his children
won't worry about financial needs and experience such a poverty-stricken life; however, as of now, he
would settle for sustaining the basic needs of his family. He says that family is important as they are the
ones who will always be there for you. His family is the reason why he needs to work hard so that he’ll
see them settled down and provide them with their needs. The important thing he values the most is his
children and also puts importance on his and his family’s well-being. He opts to follow God’s
commandment to do good unto thy neighbor as the principle he goes by because he believes that even
without monetary wealth, you still have to be held accountable for your own actions, know when you
are at wrong and apologize, and only then will he be at peace. The patient is baptized as a Roman
Catholic. Once a month, a mass is held at their church and his wife and daughters attend although he
stays behind to rest and just prays at his house. Just as his faith is important, he turns to God and prays
in times of despair. Even though he doesn't go to church as often, he strives his hardest to be a better
man. With the current events that happened, he stated that he realizes that only God can help you in
life or death situations and regrets that he never had time to spare for him and now takes this
experience as a second chance given to him to thank him for another take on life.

Well done – Gordons assessment

VII. Health History/History of Present Illness

A. Past health history

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 The patient has no history of childhood illness and significant problems at such a young age
since he was kept up to date with immunizations by his mother. There was no past hospitalization and
no previous surgeries, and although he experiences common diseases like cough, fever, and colds, he
has not experienced any severe illnesses as an adult. The patient claimed to experience allergic reactions
to sugarcane and rice pollen but no allergic reactions to any drugs or food. He has a family history of
cardiovascular disease but no record of Diabetes and Cancer. A few accidents have occurred in his
demographic location, but he has never been in one himself.

B. Family health history

The patient Rommel Claridad is a resident of Pandanon, Murcia, Neg Occ, married, with 2
daughters and currently working in the hacienda as a laborer “Karga Tapas” or in the rice field, planting
and harvesting. He works in the field from Monday to Saturday, resting on a Sunday. Every day he used
to drink whisky “Tanduay” every night to relieve fatigue after work that induced him to sleep well. His
mother has high blood pressure that they manage with medicine that is available from the health
center, while his father died 10 years ago due to a stroke. His grandparents died due to old age and that
they lived a healthy lifestyle. The patient's uncle has high blood pressure and liver disease, but some
don't as well. His children do not have any illnesses, just the occasional high fever, cough, and colds
during the rainy season.

C. History of present illness

The patient on the night of the incident was reportedly seen drinking with his friends outside a
sari-sari store. He spoke to his neighbor, who was the wife of the man who shot him. After seeing their
exchange conversation, the woman’s husband was also drunk at that time and was raging with jealousy.
Under the influence of alcohol, the man got a cane knife and stabbed Rommel. He was rushed to the
hospital accompanied by his friend with a bleeding stab wound. His friend left and went to the police
station to file a blotter report.

VII. Cephalocaudal Assessment (Pre op assessment and post op assessment) and write in bullets

Day 1 Day 3 Day 4

18
General Ap

HEENT  abrasions on  abrasions on

both hands and both hands and
feet were feet were
noted,. noted,.
 Callouses on  Callouses on
the hands have the hands have
also been also been
noted, noted,
 hair is  hair is
noticeably noticeably
thinner thinner
 tiny cracks in  tiny cracks in
the nail the nail

possibly due to aging possibly due to aging

and frequent exposure and frequent exposure
to the sun to the sun

Cardiovascular

A. General Appearance: The patient is a forty-seven (47) year old male. The patient is of a fit
physique, stands at five feet, four inches, and weighs 128 lbs or 58 kgs. The sclera is noticeably
tinted a light shade of yellow, but not too deviated. Aside from the wounds present in the
patient’s chest and abdomen, the patient is relatively healthy-looking. The presence of a stab
wound at the anterior left axillary line, T7 right midclavicular line, and in the epigastric region of
the abdomen is noted. Upon admission, the patient verbalized his pain, a result of the stab
wound, and is visibly disoriented, a result likely from the alcohol he has consumed prior to the
incident. The patient’s ambulation has been limited to reduce reports of pain and prevent

19
 irritation of the penetrated wound. The patient is maintained on a bed while awaiting admission
into the operating room. It is noted that the patient is in and out of consciousness, possibly due
to intoxication, as well as the effects of the medications administered upon admission. 

B. Skin, hair, and nails: Upon assessment,

This is an example of assessment in bullet form, just write your assessment, no explanation, omit
some unnecessary data. Follow this format

 abrasions on both hands and feet were noted,.

 Callouses on the hands have also been noted,
 hair is noticeably thinner
 tiny cracks in the nail
 possibly due to aging and frequent exposure to the sun. Tiny cracks can be observed from the
patient’s nails, another evidence of labor, however, the patient verbalized that he sets aside
time to cut his nails as long nails are painful when hit by hard crops in the field.

C. Head and Neck: Upon assessment, the patient’s head is rounded and symmetrical. No
discomfort was noted, and movements were soft when instructing the patient to flex his head
laterally, rotating, and hyperextending. There were no masses and depression palpated on the
skull. His face was smooth, with no present nodules and masses. For the patient’s neck, it was
even in size. Later, the patient is instructed to perform head movements, which were executed
with ease and were coordinated, without tenderness. The lymph nodes were not palpable. The
trachea was midline of the neck, and the thyroid gland was not visible upon inspection. The
glands ascended when swallowing but were not visible.

D. Ears: There is no presence of any infections, drainage, or painful sensation in the patient's ear.
The patient can hear sounds clearly from both ears without hearing aids and has not
experienced any dizziness or off-balance when performing various ADLs—no history of past ear
condition and usage of ear medications.

E. Eyes: The patient verbalized his ability to see his surroundings clearly but claimed to have blurry
vision only when reading. The patient does not wear glasses as he claims it to be too
troublesome. The sclera is noticeably to be a light shade of yellow but not too deviated. There is

20
 no presence of any discharges, watering, and swelling on the patient's eyes. There is no history
of any eye conditions diagnosed by a doctor, but the patient claims to use eye medications such
as eye drops to help with the rare occurrence of sore eyes. The pupillary light test showed
constriction of both pupils when exposed to light. 

F. Mouth: Upon assessment, the patient did not exhibit any signs and symptoms for having any
mouth problems. The appearance of the lips is a bit pale due to blood loss and shows dryness.
The patient is not experiencing any pain in the mouth and can open the jaw without any
problems.

G. REspiratory:  No abnormal lung sounds were heard upon auscultation;however, pre-op

respiratory rate is increased at 23 and 21 (8:00 AM and 12:00 PM respectively) during V/S taking
then returned to normal range post-op. O2 saturation is within normal levels. X-ray Chest AP
reveals hemopneumothorax on the left lung, CTT performed.

H. cardiovascularNo abnormal heart sounds were heard upon auscultation, Normal pulse rate and
blood pressure are noted at 88 bpm, 100/70 mmHg and 79 bpm, 120/70 (8:00 AM and 12:00 PM
respectively). No visible pulsations on the aortic and pulmonic areas. There is no presence of
heaves or lifts.

I. :Upon assessment,

 skin cool and dry

 Good Capillary refill less than two seconds.
 Peripheral pulses are present and equal bilaterally.
 No peripheral edema is noted.
 Hair is distributed evenly on lower extremities.

J. GIT: Upon inspection, the patient has a laceration measuring 2 inches in length on the epigastric
region of his abdomen. Abdominal girth measured at the umbilicus measures 34 inches. Minimal
bruising with yellow discoloration on the lateral side of the patient's trunk. No mass and bulges
or distention were noted upon assessment. No bowel sounds were heard during auscultation in
the four quadrants. In addition to this, minimal vascular whooshing sounds were heard in each
palpation, and percussion was not performed to avoid adding insult to the trauma.

21
 K. GUT genitourinary

L. Musculoskeletal: Upon physical assessment of the musculoskeletal system, the patient

exhibited normal body movements without prompting, however, pain radiates upon movement,
therefore further movements were deemed unnecessary. There is no noted redness, swelling,
or stiffening of any of the joints of the patient, however, a bruise forming in the area where the
right metacarpophalangeal joint is located has been noted. The patient explained the bruise to
be a result of him punching the person that stabbed him. 

M. Neurological: Upon assessment, the patient did not exhibit any signs or symptoms of having
neurological problems. The patient was responsive to any neurological stimuli. He only stated
his nervousness about his surgery but was fully aware of his surroundings.

IX. Laboratories

22
DAY 1: LABORATORY/DIAGNOSTIC TEST RESULTS: IN AT 7 AM

Result Normal value Implication

HCT 0.25 0.40 – 0.54 L/L Write the implication

here ( all abnormal lab
findings) follow this
format for your
laboratory

CBC NORMAL BLOOD NORMAL CT Scan Whole

VALUES CHEMISTRY VALUES Abdomen:
Lacerations in the
liver, perforation in
the stomach.
Hct: 0.25 0.40 – 0.54 L/L Na: 134 135 – 145 X-Ray Chest AP:
mmol/L Hemopneumothorax
left
RBC: 2.51 4.50 – 5.50 K: 3.6 3.5 – 5 mmol/L ECG: Normal Sinus
10^12/L Rhythm
Hgb: 81 130 – 180 g/L Amylase: 64.07 0 – 100 u/L

WBC: 5.1 4.5 – 11 10^9/L Crea: 69 53.04 – 114.92

umol/L
Lymphocytes: 7 25 – 35% BUN: 5.1 2.8 – 6.4 mmol/L

Mono: 3 0.00 – 15.00% FBS: 89.09 70 – 90 mg/dL

Basophil: 1 0.00 – 1.00%

Platelets: 157 150 – 400 10^9/L

DAY 3: FOLLOW-UP CBC REPORT LABS

CBC NORMAL VALUES

Hct: 0.27 0.40 – 0.54 L/L

RBC:2.73 4.50 – 5.50 10^12/L

23
 Hgb: 83 130 – 180 g/L

WBC: 9.3 4.5 – 11 10^9/L

Lymphocytes:9 25 – 35 %

Mono:3 0.00 – 15.00 %

Basophil: 1 0.00 – 1.00 %

Platelets:154 150 – 400 10^9/L

X. Pathophysiology – we need to improve our pathophysiology

24
23
 Assessment Cues Nursing Diagnosis
Subjective: Fluid volume deficit r/t
active blood loss AEB
"Nurse na bun'an ko sa
decreased Hct, RBCs, Hgb,
dughan dapit. Halin kagina
and lymphocytes
damo na dugo…..basi ma
ubsan nako dugo…." During your final NCS in
week 17 we will change
this to impaired breathing
Objective: pattern because
diaphragm is accepted,
Pale skin this one is still accepted
Hypotension
Dry skin
Weak pulse Definition:
Fluid Volume Deficit (FVD)
-Stab wound noted on or Hypovolemia is a state
anterior left axillary line, T7 or condition where the
midclavicular fluid output exceeds the
fluid intake. It occurs when
-Heavy breathing the body loses both water
and electrolytes from the
-Grimacing to pain
ECF in similar proportions.
-Continuous bleeding in Common sources of fluid
injured area
loss are the
gastrointestinal tract,
polyuria, and increased
VS: perspiration. Risk factors
of FVD are as follows:
Temp- 36.9°C
vomiting, diarrhea, GI
(Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic /
Schematic Diagram
Predisposing Factors: After 8 hours of Nsg. After 4 days of Nsg.
Intervention, the patient Intervention, the
*47 years old
will be able to: patient would be able
*Male to:
Precipitating Factors:
*Jealousy from peers Independent
Short Term:
*Alcohol consumption 1. Monitor blood loss 1. Essential for Recover from body
1. Maintain
habits recognizing potential weakness due to
sufficient blood in
life-threatening blood loss as to blood
*Presence of a cane knife the body and
hemorrhage and was replaced as soon
prevent further
↓ managing blood as possible. "Nurse
hemorrhage
product replacement luya-luya na gid ko to
As a projectile passes as soon as possible kay damo2 daan dugo
through tissue, it mayo lang may
decelerates and transfers compatible nga blood
kinetic energy to tissue. type saakon. Medyo
↓ ga-amat amat na balik
akon kusog" GOAL
Increased velocity causes PARTIALLY MET.
more damage than mass.
Kinetic energy then
increases with the square
of the velocity
2. Maintain stable 2. Change in the level of Regain stable
↓ 2. Assess patient's vital
consciousness and consciousness such as consciousness, awake
signs and mental
The space left by tissue being responsive restlessness, and responsive
status every hour
that is destroyed by the to stimuli confusion, without confusion and
penetrating object forms obtundation, and dizziness. "Wala na
a cavity. headache may galingin akon ulo,
indicate hypovolemic tapos kumpara san-o
24
HR- 88bpm suctioning, sweating,
decreased intake, nausea,
RR- 23cpm
inability to gain access to
BP- 100/70 mmHg fluids, adrenal
insufficiency, osmotic
O2 Sat- 97%
diuresis, hemorrhage,
GCS- 15 coma, third-space fluid
shift, burns, ascites, and
liver dysfunction. Fluid
LOC: volume deficit may be an
acute or chronic condition
-Semi-conscious, obtundent managed in the hospital,
outpatient center, or
home setting.
Strength/s:
-Consistent family support
Source/Reference:
-Complete assessment taken
Doenges, M. E.,
-Proper treatment to be
Moorhouse, M. F., & Murr,
given
A. C. (2019). Nurse's
pocket guide: Diagnoses,
prioritized interventions,
Weaknesses:
and rationales.
-Frail
-Lightheaded
-Pale
-Can't ambulate alone
↓ shock
In addition to the damage
to the tissues they come
into contact with, velocity
projectiles result in a
secondary cavity injury as
the object enters the
body.
↓ 3. Clean wounds and
It then creates a pressure
wave, forcing tissue out
of the way, creating a
cavity.
↓ MET.
The characteristics of the
damaged tissue
determine the severity of
the injury: the denser the
tissue, the greater the
amount of energy
Long Term:
projected.
↓ by applying direct
Penetrating trauma
causes damage to
internal organs, resulting
in shock from blood loss
and infection.
↓
Fluid Volume Deficit r/t
nga kung indi ko pag
tandugon kag
storyahon daw wala
ko kabalo kung ano
gakatabo. Subong
mayo na matyag ko"
GOAL MET.
3. Proper wound Prevent wound
blood using an cleaning minimizes infection and
3. Keep wounds and
aseptic technique the risk for wound complications for
body clean from
infection and serves as regularly cooperating
the blood
first aid intervention during wound cleaning
prior to surgery and dressing. GOAL
4. Direct pressure helps
4. Control the external
in slowing the gushing Maintain sufficient
source of bleeding
4. Preserve of blood from blood in the body that
remaining blood wounds. This helps prevents further
pressure to the
from the body and maintain blood in the hemorrhage that
bleeding site.
maintain body. might lead to
homeostasis
hypovolemic shock.
"Nurse, salamat gid sa
pag asikaso saakon
kagina. Sakit gd to pag
apply ka pressure pero
indi nagid man pwert
ka dugo". GOAL MET.
25
 active blood loss AEB
decreased Hct, RBCs,
Hgb, and lymphocytes.
5. Evaluate the extent
of the client's injury
5. Verbalize concern 5. Primary surveys aid in State relief of concern
References. with the use of a
regarding health determining and anxiety due to
Lotfollahzadeh, S., & survey
threat potentially life- extensive blood loss.
Burns, B. (2021, July 28).
threatening injuries "Nurse grabe gid bala
Penetrating Abdominal
thus conducting the kulba ko sang nakita
Trauma. National Center
immediate proper ko nga damo akon
for Biotechnology
intervention dugo, daw malipong
Information.
nako kag abi ko lapit
https://www.ncbi.nlm.nih
nako tagi-matayon
.gov/books/NBK459123/
pero na assess man ko
dayon ninyo, nadula
man akon nerbyos kay
kabalo ko indi nyoko
pag pabay-an" GOAL
MET.

6. Obtain a spun
hematocrit and
6. A hematocrit test is Determine positive
reevaluate every 30
part of a complete changes/updates
minutes.
blood count (CBC). regarding his
Measuring the hematocrit level.
proportion of red GOAL MET.
blood cells in your
blood can determine
accurate diagnosis or
monitor your
response to a

26
 treatment

Dependent

7. Conduct
laboratories such as
7. Laboratories Recognize internal
Chest X-ray, CT Scan
determine internal problems in the body
in the Abdomen,
problems found in the and understand the
CBC test, etc.
body and are the keys purpose of
in diagnosing disease laboratories in giving
and treatment of an medical intervention
injury "Kung wala ko nag pa
X-ray wala gid ko tani
kabalo nga pati iban
nga parte sang lawas
ko apektado man.
Subong na inchindihan
ko na importansya
magpa laboratoryo"
GOAL MET.
8. Administer IVF PNSS
1L as prescribed by
the Physician

8. PNSS replaces water Promote normal body

and electrolytes lost condition by replacing
from the patient due water and electrolytes
to continuous heavy lost due to active
bleeding bleeding that aids to
effective recovery
from blood loss, and
immediate wound

27
 9. Inform patient healing. GOAL MET.
regarding the
scheduled
exploratory
laparotomy to be
conducted as 9. Exploratory Perceive importance
ordered by the Laparotomy is a of surgery and display
Physician surgical incision used no regrets in signing
to examine the the waiver/consent.
abdominal organs and "Nurse, kung wala ko
aid diagnosis of any nag pa opera, basi
problems in the tigok nako subong.
abdominal region Wala labot nga gin pa
untat mo dugo ko,
tungod sa opera na
kwa ang mga tuktok
nga nagsulod sa lawas
ko halin sa binangon
kung gin antos ko lang
to kag wala nag pati
basi napatay nako"
GOAL MET.

NCP (Post OP)

Assessment Cues Nursing Diagnosis (Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic /
Schematic Diagram

28
Subjective: Acute Pain r/t surgical Predisposing Factors: After 8 hrs of nursing Independent Nsg After 8 hrs of nursing
I think this one you need to incision AEB 8/10 pain *47 years old intervention, the pt will Intervention: intervention, the pt
revise because pt is already scale and facial grimace *Male be able to: was able to:
post op he is safe only that
he experience pain due to Precipitating Factors:
surgery like Nurse sakit sakit Definition: *Jealousy from peers 1. Engage in therapeutic ● Assess for the presence ● Pain related to trauma is Engage in the
gid sg akon tinahian *Alcohol consumption regimen and and location of an indicator of the extent therapeutic regimen.
Unpleasant sensory and habits monitoring as traumatic, preoperative, of the injury. Location and Pt verbalized “Miss
*”Miss Nurse! Tabangi kami, emotional experience *Presence of a cane knife indicated to reduce and postoperative pain. character of postoperative nurse! nag dula dula
akon bana ga sinakit iya si-si, associated with actual or ↓ pain scale from 8 to 4 Use a pain scale, rating pain also can be na gamay ang sakit.
galalain gid tu sa buligi kami” potential tissue damage, As a projectile passes or lesser. discomfort from 0 (no important. Autonomic grabe gid na pakulba
as verbalized by pt’s or through tissue, it pain) to 10 (worst pain). nervous system response ni misis kagina hu,
significant other described in terms of such decelerates and transfers to pain can complicate salamat gid ah.” Pain
damage (International kinetic energy to tissue. assessment of abdominal scale of 3 out of 10
Objective: Association ↓ injury and hypovolemia. A with 1 as the lowest
*Abdominal incision, with for the Study of Pain); Increased velocity causes pain scale helps quantify and 10 as the highest.
dressing dry and clean. With sudden or slow onset of more damage than mass. pain and determine GOAL MET
dressing fully soaked with any intensity Kinetic energy then subsequent relief
bloody discharges from mild to severe and increases with the square obtained.
Since pt is hrs post op still with a duration of fewer of the velocity
normal that it is soaked than 3 months. ↓
with blood and presence of The space left by tissue 2. Dissipate or diminish ● Review intraoperative ● The presence of narcotics Dissipate nonverbal
pain is still manifested that is destroyed by the nonverbal indicators, or recovery room and droperidol in the indicators and display
*Clean and intact abdominal penetrating object forms such as grimacing; and records for the type of system potentiates no significant changes
dressing a cavity. anesthesia and narcotic analgesia, in mental status, and
*Facial grimace ↓ medications previously whereas patients remain oriented to
*Pupil dilation Source/Reference: In addition to the damage administered. anesthetized with person, place, and
*Weak in appearance with to the tissues they come Fluothane and Ethrane time. Pt held a
limited movement due to Doenges, M. E., into contact with, velocity have no residual analgesic conversation with his
pain Moorhouse, M. F., & Murr, projectiles result in a effects. In addition, with happily.
*Positioning to ease pain A. C. (2019). Nurse's secondary cavity injury as intraoperative local/ GOAL MET.
becoming slightly restless pocket guide: Diagnoses, the object enters the regional blocks have
finding positions to ease pain prioritized interventions, body. varying duration, e.g., 1–2
*Narrowed focus be more and rationales. ↓ hr for regionals or up to 2–
specific Philadelphia, PA: F.A. It then creates a pressure 6 hr for locals.
*Pain scale 8/10 (1as lowest Davis. wave, forcing tissue out
- 10 as Highest) of the way, creating a
*guarding on the abdominal cavity. 3. Control pain without ● Assess vital signs, noting ● Changes in these vital Control pain without
29
area ↓ sedation or need of tachycardia, signs often indicate acute use high doses of
*Vital Signs: The characteristics of the high doses of hypertension, and pain and discomfort. Note: analgesics. “Miss
T- 38.0 damaged tissue analgesics. increased respiration, Some patients may have a Nurse mangayo pako
PR- 91 determine the severity of even if the patient slightly lowered BP, which tani bala bulong sa
RR- 23 the injury: the denser the denies pain. returns to the normal sakit para wala nagid
BP- 130/80 tissue, the greater the range after pain relief is ko mabatyagan pero
O2 Sat- 98% amount of energy achieved. okay okay nmn sa ah.
GCS- 15 projected. kag isa pa basi ngita
↓ ● Assess causes of ● Discomfort can be caused ngitaon ta bala haw,
Penetrating trauma possible discomfort or aggravated by the madugang pa na
LOC: causes damage to other than operative presence of non-patent karun sa balayaran
Awake, distracted, and internal organs, resulting procedure. indwelling catheters, NG hahaha” as verbalized
disoriented of time, place, in shock from blood loss tube, parenteral lines by pt.
and self and infection. (bladder pain, gastric fluid GOAL MET
↓ and gas accumulation, and
Strength/s: Therapeutic Intervention: infiltration of IV fluids or
*Consistent family support Exploratory Laparotomy medications)
*Can follow instructions ↓
easily ● Evaluate the pt’s health ● Other medication use
Acute Pain r/t surgical
hx for alcohol and drug could alter effective doses
incision AEB 8/10 pain
Weaknesses: (prescribed and of analgesics or lead to
scale and facial
*Low socioeconomic status nonprescribed) use, undertreatment. All care
grimace
which could affect providers must be
effective doses of consistent in setting limits
References. analgesics. Ensure that while providing effective
Lotfollahzadeh, S., & the surgeon, pain control through
Burns, B. (2021, July 28). anesthesiologist, and pharmacologic and
Penetrating Abdominal other health care nonpharmacologic
Trauma. National Center providers are aware of methods. Psychiatric or
for Biotechnology any significant findings. clinical pharmacology
Information. consultation may be
https://www.ncbi.nlm.nih necessary.
.gov/books/NBK459123/
● Encourage the use of ● Relieves muscle and
relaxation techniques: emotional tension;
deep-breathing enhance the sense of
exercises, guided control and may improve
imagery, visualization, coping abilities
30
 music. Provide these
instructions to the
patient and family
members.
● Reassess pain level and ● More opioid is required to
assess for side effects:
- Routinely at
scheduled intervals
(e.g., q1h for the first
12 hr of opioid
therapy, q2-4h with
VS)
- With each report of
pain
- Following
administration of pain
medication based on
time to onset, time to
peak effect, and
duration of action
● To avoid dehiscence
● Encourage pt not to
cough
Collaborative ● American Nurses
● Develop a systematic
and collaborative
approach to pain
management for the
patient, using
information gathered
31
produce respiratory
depression than to
produce sedation.
Sedative effects precede
respiratory depression.
Close monitoring of the
level of sedation and
respiratory status may
prevent respiratory
depression. Also provides
information about the
need for or effectiveness
of interventions. Note: It
may not always be
possible to eliminate pain;
however, analgesics
should reduce pain to a
tolerable level.
Association & American
Society for Pain
Management in Nursing
(2005) identifies the
importance of the
involvement of patients,
family, and other health
 from pain history and care providers in data
the hierarchy of pain collection, formulation of
measurement. outcomes, and
development of the pain
management plan. The
AHRQ (2013) and APS
(2008) state self-report of
pain is the single most
reliable indicator of pain.

Dependent: ●
● Tramadol
● As prescribed, ● Morphine is the standard
administer opioid of comparison for opioid
analgesics Tramadol analgesics, and morphine
(e.g., morphine) for the or related “mu” (µ)
pain of greater severity. receptor agonists are
preferred when possible.
Monitoring side effects is
under independent ● Sedative effects precede
intervention respiratory depression.
● Assess patients Close monitoring of
receiving opioid sedation levels may
analgesics for the level prevent respiratory
of pain relief and depression
potential side effects,
including evidence of
excessive sedation or
respiratory depression.
In the presence of
respiratory depression,
reduce the amount or
frequency of the dose
as prescribed. Have
naloxone readily
available to reverse
severe respiratory
depression. ● Individualized therapeutic
32
 goals and disease
● Recognize that choice of processes are important
analgesic agent is based factors in agent selection
on three general to maximize pain relief
considerations: and minimize the
therapeutic goal, the potential of adverse side
patient’s medical effects. The difference in
condition, and drug cost of different agents
cost. used to accomplish the
same goal may be large.
Where there is no proven
or expected benefit of
using one medication in
preference to another to
accomplish the desired
goal, the less costly
medication should be
considered. The right
medication is the one that
works with the fewest side
effects.

● The use of PCA

● Patient-controlled
analgesia (PCA)
necessitates detailed
patient instruction. PCA
must be monitored closely
but is considered very
effective in managing
acute postoperative pain
with smaller amounts of
narcotic and increased
patient satisfaction.

● TENS may be useful in

● Monitor use and/or reducing pain and the
effectiveness of amount of medication
transcutaneous required postoperatively.
electrical nerve
33
 stimulation (TENS).

Assessment Cues Nursing Diagnosis (Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic /
Schematic Diagram

Subjective: Risk for infection r/t Predisposing Factors: After 8 hours of nursing After 8 hours of
“Kagina ko gnoperahan pero surgical incision *47 years old intervention, the patient nursing interventions,
kasakit kaayo sa gnbun’an sa *Male will: the patient was able
lawas ko nurse” as Definition: to:
verbalized by the patient. At increased risk for being Precipitating Factors: Short term: Independent:
invaded by pathogenic *Jealousy from peers - Identify the risk 1. Noted risk factors for the To help the patient identify Identify the risk
organisms at the incision *Alcohol consumption factors that are occurrence of infection in the present risk factors that factors present.
Objective: site. habits present. the incision. may add up to the infection. GOAL MET.
* *Presence of a cane knife
*presence of Abdominal Wounds involving injury to ↓
incision, at the (write the soft tissues can vary from As a projectile passes - Have a partial 2. Observed for localized To evaluate the character, Understand infection
exact location) with dressing minor tears to severe through tissue, it understanding of signs of infection at presence, and condition of the control.
dry and clean. crushing injuries. The decelerates and transfers infection control. insertion sites of invasive present infection. GOAL MET.
*Facial grimace decision to suture a kinetic energy to tissue. lines, surgical incisions, or
*Weak in appearance wound depends on the ↓ wounds.
*Clean and intact abdominal nature of the wound the Increased velocity causes
dressing time since the injury was more damage than mass. - Demonstrate 3. Routinely monitor the These laboratory values are Flatulence was noted
34
*Vital Signs: sustained the degree of Kinetic energy then passing of gas or patient’s white blood cell closely linked to the patient’s around 11 AM.
T- 37.3 contamination. increases with the square flatulence. count, serum protein, and nutritional status and immune GOAL MET.
PR- 79 of the velocity serum albumin. function.
RR- 21 ↓ Long term:
BP- 120/70 Source/Reference: The space left by tissue - Client’s full 4. Make health teachings To help the client Identify the risk
O2 Sat- 98% that is destroyed by the knowledge in especially in the modify/change/avoid some of factors of the
GCS- 15 NANDA International, penetrating object forms identifying the risk identification of the environmental factors infection.
Nursing Diagnoses, a cavity. factors of the environmental risk factors present which could reduce GOAL MET.
LOC: Eleventh Edition, p. 195 ↓ infection. that could add up on the incidence of infection.
*Patient unresponsive to In addition to the damage infection.
stimulus ??????? wht at do u Nettina, Sandra M. (2003) to the tissues they come
mean Lippincott’s pocket manual into contact with, velocity - State symptoms 5. Encourage the patient to It helps thin out secretions State the symptoms to
of nursing practice. 2nd projectiles result in a of infection which increase fluid intake if not and replace fluid loss during be aware of.
Strength/s: edition. secondary cavity injury as to be aware of. contraindicated. fever. It also prevents stasis of GOAL MET.
*Strong family dynamic the object enters the 6. demonstrate proper urine by promoting diluted
body. wound dressing urine and frequent emptying
Weaknesses: ↓ of the bladder.
*Low socioeconomic status It then creates a pressure
wave, forcing tissue out
of the way, creating a
cavity. - Demonstrate Antibiotics will help kill and Demonstrate proper
↓ appropriate care Dependent: stop the proliferation and care of the infection-
The characteristics of the of the infection- 1. Administer growth of the bacteria which prone sites.
damaged tissue prone sites. antibiotics as could cause infection. GOAL MET.
determine the severity of ordered by the
the injury: the denser the physician.
tissue, the greater the - Be free from any Prospective surveillance for Reduce any signs and
amount of energy signs and This is independent nursing healthcare-acquired infection symptoms related to
projected. symptoms related intervention on hematology-oncology units infection.
↓ to infection. 2. Observe and report should include fever as the GOAL MET.
Penetrating trauma signs of infection single most common and
causes damage to such as redness, clinically important entity.
internal organs, resulting warmth, discharge,
in shock from blood loss and increased body Implement dietary changes to
and infection. temperature support recovery and address
↓ antibiotic side effects.
Therapeutic Intervention:
Exploratory Laparotomy 3. Refer for nutritional
35
 ↓ evaluation.
Risk for infection r/t
surgical incision

References.
Lotfollahzadeh, S., &
Burns, B. (2021, July 28).
Penetrating Abdominal
Trauma. National Center
for Biotechnology
Information.
https://www.ncbi.nlm.nih
.gov/books/NBK459123/

36
XII. Drug Studies

39
40
41
42
43
44
45
46
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48
49
XIII. Health Teaching - in your HTP note Pre and Post Op
Medications Exercise Treatment Hygiene Outpatient Diet

Generic Name:
Omeprazole
Brand Name:
Omepron
C - Proton-pump Inhibitor
(Gastrointestinal/Hepatobiliary
Drugs)
H - The patient exhibits fewer recommended
symptoms of overproduction of
acid in the stomach.
Onset: 1 hour
Peak: 30 mins - 3 and a half lead to unnecessary bruising,
hours.
Duration: 3 - 4 days
E - STAT; At the exact time the
medication is ordered, @ 2 AM.
C-
● Caution patient to avoid
ingesting alcohol to
avoid gastrointestinal
irritation.
● Report symptoms of
severe headache,
unresolved severe
diarrhea, or changes in
respiratory status.
● Inform the patient to
Pre op
Breathing exercises to improve
oxygenation
Leg exercises
Add more data
Other exercise is still not
Post op
Note: Doing strenuous exercises
after a surgical procedure can
swelling, fluid buildup, wound
separation, and possibly
infection.
● Get plenty of rest
- Sleep is very important
when healing after
surgery
- To reduce the risk of
injury, make sure to use
the log roll method to
get out of bed
● Limit movement
- For 4 to 8 weeks after
your surgery you do not
lift, pull, or push
Pre op HANDWASHING - Removes
 Cover stab germs from hands. This helps
wounds with prevent infections.
sterile dressing
 Oxygen Home care
administration These guidelines will help you
 Administration care for your wound at home:
of TT ● Keep the wound clean
and dry. If a bandage is
applied and it becomes
wet or dirty, replace it.
 Surgical repair, Otherwise, leave it in
exploratory laparotomy place for the first 24
 hours.
 In writing be more
specific refer to the ● If the surgical tape was
case scenario and you used, keep the area
may add ideal Tx that is clean and dry. If it
not mentioned in the becomes wet, blot it dry
case with a towel.
● Do not use skin
If not necessary, do not cleansers, alcohol,
use gauze, because it
peroxide, iodine, or
can cause pain, while soaps with antibacterial
products such as chemicals on the wound
hydrogels, hydrofibers, unless your provider
alginates, and soft tells you to. These can
silicone dressings are damage the wound
least likely to cause any tissue and slow your
pain. healing.
- Using over-the-counter ● Do not put any lotion,
or prescribed pain cream, or herbal
- Instruct patient to have Problems with digestion can
enough and proper rest arise post-operation, this is due
to the inflammatory response of
- Inform patient to refrain the body towards intestinal
from doing vigorous trauma and manipulation during
activities that may cause surgery.
sudden
dehiscence/evisceration The patient will be advised to
of wound follow a clear liquid diet for
around 1 to 3 days post-surgery
- Encourage patient to until it can be tolerated, as solid
follow strict compliance food still can’t be tolerated by
of medicine for a quick the body, a clear liquid diet
recovery could be any of the following:
- Inform patient to have ● Water
follow-up ● Clear, fruit juices
consultations/check-ups ● Tea
to monitor body's ● Clear soup or broths
condition ● Popsicles
- Inform patient to have Tips for the patient so that they
wound dressing one to are able to return to their
three times a week to normal diet as soon as possible:
avoid infection
● Eat smaller portions, as
- Remind patient to have larger portions can
proper hand washing irritate your GI tract.
before touching the ● Drink plenty of fluids.
wound/stitches to ● Have protein with each
prevent microorganism meal (e.g., lean meat,
transfer fish, chicken, eggs,
mung beans)
- Inform patient to use

50
 report the following anything that weighs medications (ibuprofen remedies on or around only soft clean towel When the patient is able to
adverse reactions: chest more than 10 pounds. or acetaminophen) and the wound unless when cleaning the tolerate a clear fluid diet, they
pains, rapid breathing, Do not perform any dressings to reduce or instructed by the wound to prevent can fully return to their normal
palpitations, headache, prevent any pain from provider. irritation diet.
movement or exercises
dizziness, and rashes. radiating.
that use your abdominal - Instruct patient to You may add sample diet or
K- muscles. - Some wounds may need Bathing or Showering immediately report to type to food to take when they
● Encourage frequent antibiotics ● Your provider will let the physician if sudden are discharge
● Assess the patient’s positioning while on you know when it is OK wound bleeding occurs
gastrointestinal system: bed rest - Contact immediately if to bathe after you come
monitor bowel sounds, - Change your position there is an infection: home. You may need to - Remind the patient to
periodically check the redness, increasing take sponge baths for apply antibiotic cream
every hour while awake
abdomen for pain or pain, swelling, or pus at several days until your to the incision site to
distention and assess - Prevent sores, pressure the site. wound has healed keep the wound moist
for appetite loss. ulcers, problems like enough to shower. Keep and help heal quicker.
● Assess other lung infection, blood - Ask if a tetanus shot is in mind:
medications the patient clots, and weak muscles needed. ● Soaking your wound - Instruct patient to apply
will be taking to could cause it to new, dry and clean
determine the drug’s After the pain in the incision is - Minimize further reopen. bandages. Never re-use
effectiveness and to inflammation: POLICE ● Remove the dressing previous bandages.
gone:
avoid unnecessary drug - Protection before bathing unless - Follow schedule for
interactions. - Optimal told otherwise. Some doctors consultation for
● Monitor therapeutic ● Advise patient to Loading: removal of suture
dressings are
effectiveness and perform deep breathing controlled waterproof.
adverse reactions at the and coughing exercises increments of ● If your provider gives
beginning and - Breathe deeply and mechanical you the OK, gently rinse
periodically throughout cough every hour while stress to the your wound with water
therapy. affected limb as you bathe. Do not
you’re awake
__________________________ - Ice rub or scrub the wound.
- help your breathing, - Compression
clear your lungs, and
● Gently pat dry the area
Generic Name: - Elevation around your wound
Metoclopramide lower your risk of
with a clean towel. Let
pneumonia. the wound air dry.
Brand Name: ● Foot and leg exercises Cover with a new
Reglomar (ankle pump, ankle dressing.
circle) ● If allowed, apply a thin
C - Prokinetic Drugs

51
 - prevent problems like layer of antibiotic
H - Blocks dopamine receptors blood clots ointment on the wound
(at high dose) and serotonin ● Walking prior to wound dressing.
receptors in chemoreceptor
- the first time you get
trigger zone of CNS; and
sensitizes tissues to up, it’s important to
acetylcholine; increases upper have a nurse or physical
GI motility but not secretions; therapist with you.
increases lower esophageal - take short rests in
sphincter tone between walks.
- move slowly, it’s normal
Onset: 1-3 min
to feel dizzy and
Duration: 1-2 hr
Peak serum time: 15 min uncomfortable when
E - 500 mg IVTT q6H you first get up
(6am, 12nn, 6pm, & 12am) - walk in the hall several
times a day
C-
*Fatigue *Headache
*Restlessness *Dizziness
*Sedation *Diarrhea
*Galactorrhea *Nausea
*Gynecomastia *Impotence
*Neuroleptic malignant
syndrome
*Hematologic abnormalities

K-

● Metoclopramide is an
antiemetic that also
promotes gastric emptying.
● 30 minutes before meals
and at bedtime; use
injectable dosing only if
severe symptoms are
present

52
 ● Risk of developing tardive
dyskinesia increases with
treatment duration and
total cumulative dose
● Discontinue with signs or
symptoms of tardive
dyskinesia
__________________________

Generic Name:
Ceftriaxone

Brand Name:
Rocephin

C - Cephalosporins, 3rd
Generation

H - Ceftriaxone is a
cephalosporin (SEF a low spor
in) antibiotic. Ceftriaxone is
used to treat many kinds of
bacterial infections, including
severe or life-threatening forms
such as E. coli, pneumonia, or
meningitis. Ceftriaxone is also
used to prevent infection in
people having certain types of
surgery.

E - 1.5 mg IVTT ANST as loading

dose

C - The following conditions are

contraindicated with this drug.
Check with your physician if you
have any of the following:

53
 - diarrhea from an
infection with
Clostridium difficile
bacteria.
- A type of blood disorder
where the red blood
cells burst called
hemolytic anemia.
- Liver problems
- Disease of the
gallbladder
- Severe renal
impairment

You should not use ceftriaxone

if you have ever had a severe
allergic reaction to any type of
cephalosporin antibiotic
(Omnicef, Keflex, and others).
Do not use ceftriaxone in a child
without a doctor's advice, and
never give more than the child's
prescribed dose.

K - Instruct patient to notify

physician immediately of signs
of superinfection, including
black, furry overgrowth on
tongue, vaginal itching or
discharge, and loose or foul-
smelling stools.

-Instruct patient and

family/caregivers to report
other troublesome side effects
such as severe or prolonged
fever, skin problems (rash,

54
hives), diarrhea, or signs of
gallstones.

__________________________

Generic Name:
Clostridium tetani toxoid
antigen

Brand Name:TE Anatoxal Berna

C - Vaccine

H - This vaccine is given to

provide immunity against
tetanus in adults and children 7
years or older. Vaccination is the
best way to protect against this
life-threatening disease.
Vaccines work by causing the
body to produce its own
protection (antibodies).

E -0.5 ml/amp, give 1 ampule via

deep IM, now at right deltoid

C - Inform patient of possible

side effects:
- Mild fever
- Joint pain
- Muscle aches
- Nausea
- Tiredness
- Injection site reactions
such as pain, itching,
redness.
K - Instruct patient to report any

55
side effects experienced if any,
as well as any adverse reactions
to the medication. Monitor vital
signs as mild fever can be a
possible side effect.

__________________________

Generic Name: Tetanus

Antitoxin (Anti-Tetanus Serum
or ATS)

Brand Name: Equine

C - Immunologic Agent

H - Neutralizes toxin before its

transport to the nervous system
via circulation. Antitoxin also
can neutralize toxins locally and
prevent their systemic
absorption.

E - 3,000 IU/amp, 1 ampule IM,

now, ANST @ left deltoid

C -Educate patient that this

medication is used to prevent
tetanus

- Inform the client that

this drug may have side
effects but immediately
inform if side effects are not
in common

- Even though it may be

56
 rare, immediately inform
the nurse or physician right
away if you have any of the
following signs or symptoms
that may be related to very
bad side effects like Signs of
allergic reactions, such as
rash; hives; itching; red,
swollen, blistered, or
peeling skin with or without
fever; wheezing; tightness in
the chest or throat; trouble
breathing, swallowing, or
talking; unusual hoarseness;
or swelling of the mouth,
face, lips, tongue, or throat.

K - Sensitivity testing and

desensitization. Prior to the use
of tetanus antitoxin, an
intradermal skin test or a
conjunctival test for serum
sensitivity should be performed.
Adrenaline (epinephrine) should
be available during sensitivity
testing for immediate treatment
of hypersensitivity reactions if
they occur
- Use with caution in
patients with isolated
immunoglobulin A
deficiency or a history of
systemic hypersensitivity to
human immunoglobulins.
- Bleeding disorders: Use
with caution in patients

57
 with thrombocytopenia or
coagulation disorders; IM
injections may be
contraindicated.
- Not for intravenous
administration.

58
XIV. Conclusion and Recommendations

CONCLUSION

Stab wounds are classified as penetrating trauma which are injuries caused by foreign objects
penetrating through the skin and other tissues, damaging the underlying structures, and leaving a gaping
wound. Without immediate management, these cases can cause an impediment to the quality of life of
the victims. In this report, the student nurses involved in the case have acquired a new set of knowledge
and abilities concerning the care of a patient that has sustained physical trauma, a rather unfamiliar
territory compared to the previously handled cases that mostly involved disease processes. To formulate
effective care plans and for independent interventions to take place, the student nurses meticulously
assessed the patient in a cephalocaudal manner. A comprehensive assessment of the patient’s health
history was then performed to identify risk factors that would disrupt the therapeutic intervention.
Along with these, the student nurses also collaborated with fellow health care team members to
monitor the progress, address deviations, and fully utilize the capacities of each member. The
subsequent actions carried out by the healthcare team proved effective in preventing further damage to
the affected organs, thus posits a positive effect on the healing process. 

With all the data, assessments, interventions, and physical manifestations displayed by the
patient, the student nurses have concluded that the case has been managed well by the healthcare
team.

RECOMMENDATIONS (formulate 2 for student nurse, to patient is ok na)

For the Patient. We greatly recommend a change in lifestyle, especially with physical and social
interactions. The regular consumption of alcohol can permanently damage the filtering abilities of the
kidneys and the liver.

We also recommend the teaching of basic first aid for the patient, to inform him that if the next time he
witnesses a stabbing incident or he himself will be stabbed again, God forbid, it is favorable to contain
the penetrating weapon within the wound to avoid further damages to the surrounding tissues and can
decrease the loss of blood.

All in all, we applaud the patient for immediately seeking help in a health institution.

59
For the Student Nurses. We greatly recommend sufficient time to properly perform a comprehensive
cephalocaudal assessment and prompt implementation of nursing intervention.

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%7E:text=Penetrating%20trauma%20is%20an%20injury,explosive%20devices%2C%20and
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American College of Surgeons. Wound Home Skills Kit: Surgical Wounds.
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Clostridium tetani toxoid antigen (formaldehyde inactivated). Uses, Interactions, Mechanism of Action |
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Kate, V. F. (2021, June 8). Exploratory Laparotomy: Background, Indications, Contraindications.
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Kim, H. O., Kang, M., Lee, S. R., Jung, K. U., Kim, H., & Chun, H. (2018, October Patient-Controlled
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