NCM 118 Lab Hemorrhagic Shock Revised

Republic of the Philippines
TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE

DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300 Tel.no:(045) 493-1865 Fax: (045) 982-0110
website: www.tsu.edu.ph
Awarded Level III Phase2 Status by the Accrediting Agency of Chartered Colleges and
Universities in the Philippines (AACCUP)
A Clinical Case Study

Presented to the
Faculty of the Department of Nursing
College of Science
Tarlac State University
Tarlac City
In Partial Fulfillment
Of the Requirements for
NCM 118 LABORATORY
HEMORRAGHIC SHOCK
Submitted by:
FELICIANO, Jenard
FLORES, Arliah Grace
HATIYA, Rhoda
MIRANDA, Lavinia
MORTOS, Angelou
ROMERO, Deinielle Ingrid
ROMERO, Pamela
RUFINO, Leslie Kriztel
SANTOS, John Radley
BSN 4-2 (Clinical Group 3)
Submitted to:
Anne Mrytle M. Lorenzo RN, MSN-MAN
Clinical Instructor
December 2021
Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
BSN 4-2 GROUP 3 HEMORRHAGIC SHOCK
2
DEPARTMENT OF NURSING
Villa Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
VISION
Tarlac State University is envisioned to be a premier university in Asia Pacific Region.
MISSION
Tarlac State University commits to promote and sustain the offering of quality and
programs in higher and advanced education ensuring equitable access to education for
people empowerment, professional development, and global competitiveness.
Towards this end, TSU shall:
Provide high quality instruction trough qualified, competent and adequately trained
faculty members and support staff.
Be a premier research institution by enhancing research undertakings in the fields of
technology and sciences and strengthening collaboration with local and international
institutions.
Be a champion in community development by strengthening partnership with public and
private organizations and individuals.
GOAL
The goal of the Nursing Department is on the holistic development of the person to be a
professionally competent and caring nurse imbued with the following core values of love
of God, love of country and service to man.
OBJECTIVES
To prepare graduates for the practice of nursing in various settings by providing the
broadest basic education, skills, and competencies for future leadership positions in
nursing.
To develop among the students the spirit of compassionate caring, quality of service,
social insight, and commitment in health care of the nation.
To continue to strengthen and facilitate health research initiatives and maintain active
outreach programs with the community through coordination and collaboration of
undertakings
3
Table of Contents
TABLE OF CONTENTS..................................................................................................3
CASE SCENARIO...........................................................................................................4
I. INTRODUCTION........................................................................................................... 4
II. NURSING PROCESS..................................................................................................7
A. Assessment………………………………………………………………………………7
Personal Data......................................................................................................................7
Lifestyle (Habits, Recreational, Hobbies......................................................................7
Family Health History of Illness.....................................................................................7
History of Past Illness.......................................................................................................8
History of Present Illness.................................................................................................8
13 Areas of Assessment................................................................................................10
Laboratory and Diagnostic Procedures.....................................................................17
Anatomy and Physiology...............................................................................................24
Pathophysiology (Book-Based)....................................................................................26
B. Planning................................................................................................................ 30
Medical Management......................................................................................................55
Surgical Management.....................................................................................................57
C. Implementation………………………………………………………………………….50
D. Evaluation............................................................................................................. 60
III. CONCLUSION.......................................................................................................... 62
IV. RECOMMENDATION...............................................................................................63
V. REVIEW OF RELATED LITERATURE.....................................................................64
VI. BIBLIOGRAPHY:.....................................................................................................66
4
CASE SCENARIO
A 22-year-old woman was transported to the trauma bay following a motorcycle
crash. She was immobilized on a spine board with a cervical collar in place. A single
large bore intravenous catheter was placed pre-hospital and a crystalloid bolus was
initiated. She was able to speak, and she had bilateral breath sounds. There were no
external signs of bleeding. Her pulse was 142 beats/min and thready. Her right chest
and abdomen were tender, and her pelvis was mechanically unstable. She had
deformity of her right femur and left foot. She was placed on the monitor and noted to
have an axillary temperature of 96 °F, blood pressure of 75/38 mmHg, respiratory rate of
36, and oxygen saturation of 90%. Her chest x-ray showed multiple right-sided rib
fractures but a normal mediastinal contour, and her pelvic x-ray demonstrated a 3 cm
pubic symphyseal diastasis. She had a positive focused assessment with sonography in
trauma (FAST) exam in the right upper quadrant and around the bladder. Point of care
venous blood gas testing indicated a pH of 7.28 with a lactate of 6 mg/dL and a base
deficit of 12.
This patient’s assessment of blood consumption (ABC) score was 3 on presentation;

so emergency release blood products were taken from the trauma bay refrigerator, and
the institution’s massive transfusion protocol was initiated. During this resuscitation,
equal parts packed red blood cells, fresh frozen plasma, and platelets were given as
concurrently as possible. After applying a pelvic binder, a femoral arterial catheter was
placed percutaneously. Because the chest x-ray demonstrated a normal mediastinal
width, there were no clear contraindications to resuscitative endovascular balloon
occlusion of the aorta (REBOA). With ongoing hypotension and a positive FAST exam, a
REBOA catheter was advanced into the distal thoracic aorta (Zone 1) and inflated. The
patient was taken emergently to the operating room for abdominal exploration, pre-
peritoneal pelvic packing, and pelvic external fixation. Over the next 6 h she received
10 units of packed red blood cells, 10 units of plasma and 2 units of apheresis platelets.
Care was taken to include empiric calcium chloride administration during blood product
transfusion. Thromboelastographic (TEG) also indicated a need for cryoprecipitate and
demonstrated increased fibrinolysis; so tranexamic acid (TXA) was also given. Post-
operatively, her hemodynamics improved, her lactate rapidly cleared, and her TEG
normalized.
5
INTRODUCTION
Hemorrhagic shock is a condition of reduced tissue perfusion, resulting in the
inadequate delivery of oxygen and nutrients that are necessary for cellular function.
Whenever cellular oxygen demand outweighs supply, both the cell and the organism are
in a state of shock (Udeani, 2021)
Life-threatening decreases in blood pressure often are associated with a state of

shock – a condition in which tissue perfusion is not capable of sustaining aerobic
metabolism. Shock can be produced by decreases in cardiac output (cardiogenic), by
sepsis (distributive), or by decreases in intravascular volume (hypovolemic). The latter
may be caused by dehydration from vomiting or diarrhea, by severe environmental fluid
losses, or by rapid and substantial loss of blood. Hemorrhagic shock is a type of
hypovolemic shock, where intravascular blood loss and consequent alterations in the cell
due to the hypoxia result in tissue and organ dysfunction, leading to death once a certain
threshold level is exceeded (Hooper, 2021)
Hemorrhage is a medical emergency that is frequently encountered by

physicians in emergency rooms, operating rooms, and intensive care units. Significant
loss of intravascular volume may lead sequentially to hemodynamic instability,
decreased tissue perfusion, cellular hypoxia, organ damage, and death. Though most
thought of in the setting of trauma, there are numerous causes of hemorrhagic shock
that span many systems. Blunt or penetrating trauma is the most common cause,
followed by upper and lower gastrointestinal sources. Obstetrical, vascular, iatrogenic,
and even urological sources have all been described. Bleeding may be either external or
internal. A substantial amount of blood loss to the point of hemodynamic compromise
may occur in the chest, abdomen, or retroperitoneum. The thigh itself can hold up to 1 L
to 2 L of blood. Localizing and controlling the source of bleeding is of utmost importance
to the treatment of hemorrhagic shock (Tiangco, 2021)
Trauma remains a leading cause of death worldwide, with approximately half of

these attributed to hemorrhage. In the United States in 2001, trauma was the third
leading cause of death overall and the leading cause of death in those aged 1 to 44.
While trauma spans all demographics, it disproportionately affects the young, with 40%
of injuries occurring in ages 20 to 39 years by one country’s account. Of this 40%, the
greatest incidence was in the 20 to 24-year-old range. The preponderance of
hemorrhagic shock cases resulting from trauma is high. For one year, one trauma center
reported 62.2% of massive transfusions occur in the setting of trauma. As patients age,
physiological reserves decrease, the likelihood of anticoagulant use increases, and the
number of comorbidities increases. Due to this, elderly patients are less likely to handle
the physiological stresses of hemorrhagic shock and may decompensate more quickly.
(Hooper & Armstrong, 2021)
According to Philippine New Agency (2018), fourteen out of the 241 evaluated
cases died during treatment translating to an in-hospital mortality rate of 5.8%. Of these
6
14 deaths, six (43%) had traumatic brain injuries (e.g., intracranial hemorrhage or brain
herniation), four died of septic shock, and the remaining deaths were attributed to
hemorrhagic shock, unrecognized upper airway obstruction and acute respiratory
distress syndrome. The biggest problem of injury and death, among them, is loss of
blood and organ damage due to the trauma. According to the latest data of the
Department of Health (DOH), death due to accidents is fifth among the 10 causes of
mortality among Filipinos. Around 36,329 people died from all forms of accidents. This
figure translates to 38.6 percent rate for every 100,000 Filipinos.
We, BSN 4-2 clinical group 3, chose this case study, for it will assist us widen our
knowledge about the disease we are dealing with. As student nurses, we are involved in
determining what appropriate nursing managements are to be done to the patient we are
dealing with. By doing so, we can improve our skills and expand our knowledge to
provide standard nursing care, as well as increase our critical thinking abilities and
comprehension not only of the case but also of its differences and similarities with other
cases for the study's progress and success. Knowing about this case study can provide
other nursing students with information that can help them provide nursing care
management and interventions to their patients. Aside from comprehending the pertinent
health condition, this case will investigate additional elements that can improve our
knowledge, skills, and attitude in the field of nursing practice.
7
General Objectives:
The general objective of this study is for us, as student nurses to enhance our
skills, widen our concepts to have deeper understanding on the disease and apply more
appropriate treatment and nursing management, to fulfil and achieve the patient’s
optimal well-being requirement.
Specific Objectives:
a.) To be able to perform thorough nursing assessment.

b.) To formulate a nursing diagnosis in relation with the client who had this kind of
condition.
c.) To develop an effective and quality nursing care plan which the patient may
benefit.
d.) To implement and perform planned nursing management indicated for the patient.
e.) To evaluate the nursing interventions performed by the patient.
8
II. NURSING PROCESS

A. ASSESSMENT
Personal Data
Name: Patient X
Age: 22 years old
Height: 5’6
Weight: 47 kg
Address: Tarlac City
Gender: Female
Date of Birth: March 04, 1999
Religion: Roman Catholic
Civil Status: Single
Occupation: Unemployed
Nationality: Filipino
Admitting diagnosis: HEMORRHAGIC SHOCK
Environmental Status
Patient X is currently living in Tarlac together with her family. Their house is
bungalow-type made up of wood and concrete. Their house is near the highway
along with other houses, and they have water pump as their main source of
water. Garbage and waste disposal are observed, garbage-collecting truck
collects their waste every Tuesday and Wednesday morning. They use
motorcycle, jeepneys, and buses as their mode of transportation when they go to
other places.
Lifestyle (Habits, Recreational, Hobbies)

Patient X does eat her meals 2-3 times a day, regularly. She never skips her
meals and has no specific type of diet and eats whatever is served to her. She
recently graduated college and is currently unemployed. She helps at the house
chores, and usually do the dishes and clean their house.
Family Health History of Illness

Patient X is the eldest of 2 siblings. Her grandparents in her Paternal side are
both alive, but her grandmother have hypertension, same goes with her father. On
her maternal side, her grandfather died from a heart attack 2 years ago, while her
grandmother is alive and well. Her aunts from both sides of the family are healthy
9
and does not have any health problems same goes with her mother and younger
brother.
History of Past Illness

Patient X was fully immunized, and she has no health-related problem or
condition, aside from when she was 10 years old, she had fever and diarrhea.
History of Present Illness

Patient X was rushed to the hospital due to trauma following a motorcycle crash.
She was immobilized on a spine board with a cervical collar in place. Upon
admission the patient was able to speak and had bilateral breath sounds. There were
no external signs of bleeding. Her pulse was 142 beats/min and thready. Her right
chest and abdomen were tender, and her pelvis was mechanically unstable. She had
deformity of her right femur and left foot.
10
GENOGRAM
Paternal Side Maternal side
Grandfather, Grandmother, Grandfather, Grandmother,

65 years old. 67 years old. 69 years old. 65 years old.
Male
Aunt, 45 years Father, 49 Mother, 51 Aunt, 47 years

Female
old years old years old old
Deceased
Hypertension
Patient, 22 Brother, 16
Heart attack yrs old years ols
11
13 AREAS OF ASSESSMENT
I. Social Status
Patient X is a 22 years old woman, Lives in Concepcion, Tarlac. She lives with
her family. According to patient X, she loves to hang out with their relatives and friends.
Patient X has a good relationship with her family members.
Norms:
Social status includes family relationship or friends that state the patient's support
system in times of stress and in need. It meets a fundamental human need for social
ties, making life less stressful and social support buffers the negative effects of the
stress, thus, indicating indirectly contributing to good health outcomes (Kozier, 2016).
Analysis:
Patient X's social status is normal. She has a good relationship with her family and
friends.
II. Mental Status
General Appearance and Behavior
Patient X is well groomed and organized in her appearance. She looks weak but
able to answer all the questions asked to her with all sincerity and confidence. Patient X
is not erect posture, and she cannot move properly. She can maintain eye contact and
alertness during the interview.
Level of Consciousness
Patient X shows awareness and consciousness in her surroundings by being

able to respond and think properly.
Orientation
Patient X can tell the exact date, time, and the place where she was admitted.
She is aware in the reason of her hospitalization.
Speech
Patient X can speak clearly and express herself during the interview.
Intellectual Function
Patient X was able to understand all of the questions during the interview and the
purpose of conducting it. She could think properly on her own without the need of
companion to help her.
Norms:
12
The patient should appear relaxed with the appropriate amount of concern for the
assessment. The patient should exhibit erect posture, smooth gait and symmetrical body
movement. The patient should be clean and well-groomed and should wear appropriate
clothing for age, weather, and socioeconomic status. Facial expressions should be
appropriate to the content of the conversation and should be symmetrical. The patient
should be able to produce spontaneous, coherent speech. Content of the message
should match the patient educational level. The patient should be correctly responding to
questions and to identify all the objects as requested. Denial and poor eye contact is
normal response on the first interaction that may be due to uneasiness on the presence
of a stranger or an attempt to screen or ignore unacceptable realities by refusing to
acknowledge them. The patient should demonstrate a realistic awareness and
understanding of self. The patient should be able to evaluate and act appropriately in
situations requiring judgment. Thought process should be logical, coherent and goal-
oriented. Thought content should be based on reality. (Health Assessment and Physical
Examination, 3rd Edition)
Analysis:
Being responsive and able to answer questions accordingly are the major
determinants, which indicate patient’s mental capabilities are still functioning well. He
has a normal mental status.
III. Emotional Status
While assessing Patient X, she was quite lacking of ease because of her
condition. But she still handle to cooperate with us and able to answer our questions
Norms:
Normally, the patient should have the ability to manage stress and to express
emotion appropriately. It also involves the ability to recognize, accept and express
feelings and to accept one’s limitations. (Kozier & Erb's, 2016).
Analysis:
Patient X was able to answer our questions even though she has an illness to
bear. She only subjects to the questions that is being asked to her, other than that she is
quiet.
IV. Sensory Perception
Patient X has normal hearing acuity by doing the watch tick test. She responded
that she can hear the tick of the watch. Her sense of smell is normal whereas the patient
was asked to smell a spray of alcohol on one hand and she said that she can smell it
well and both nares are noted to be patent. Her sense of taste appeared to be normal as
13
she stated she can appreciate the flavor of the food that she eats almost every day. For
the sense of sight, Patient X is not wearing eyeglasses and claimed to be normal vision
of 20/20. Sense of touch is normal since the patient could easily react to the inflicted
pain and certain cold or warm temperature against her skin.
Norms:
Each of the five senses becomes less efficient as the age advances. Changes result
in loss of visual acuity, less power of adaptation to darkness and dim light, decreased in
accommodation to near and far objects. The loss of hearing is the ability related to aging
effects people over age 65. Gradual loss of hearing is more common among man than
women, perhaps because men are more frequently in noisy work environment. Older
people have a poorer sense of taste and smell and are less stimulated by food than
young. Loss of skin receptors takes place gradually, producing in increased threshold for
sensations of pain, touch, and temperature. (Fundamentals of Nursing 7th edition
Barbara Kozier)
Analysis:
Patient X’s sense of hearing and sense of touch are normal even his sense of smell
and taste. The patient was able to read the big letter in the Snellen chart and the small
letters in the smaller line she was able to read it.
V. Motor Status
Upon inspection we noted any asymmetry of muscle; unilateral atrophy will often
indicate weakness. We assess the upper extremities, the patient asked to raise her arms
parallel to the floor or bed, and then have her resist when she try to push them down.
We do the same for the lower extremities, having her raise her legs and resist when she
push them down. While the patient in bed, we assess motor strength bilaterally. Have
the patient flex and extend her arm against your hand, squeeze your fingers, lift her leg
while you press down on her thigh, hold her leg straight and lift it against gravity, and flex
and extend her foot against your hand. Using the motor scale the grade of the patient is
+1, she has no movement.
Norms:
Normal motor stability includes the ability to perform different activities without
causing pain and discomfort. It should be firm and have coordinated movements. (Estes,
2011)
Analysis:
In the test done, the patient had difficulty in moving her extremities because of
her fracture. Her grade in motor scale is +1 which indicates that there is no movement.
VI. Temperature
14
The table shows the temperature of the patient during her confinement:
Date Time Temperature Analysis
December 5, 2021 8:00 am 35.5 °C Abnormal
Norms:
The normal range for adults is considered to be between 36°C and 37.5 °C.
Febrile is marked or caused by fever (Kozier & Erb’s, 2016).
Analysis:
Patient X noted to have abnormal body temperature of 35.5 °C Body temperature

decreased rapidly following the onset of hemorrhage, and by the end of hemorrhage,
body temperature dropped (Mizushema, et al. 2000).
VII. Respiratory Status
The table shows the respiratory status of the patient during her confinement:
Date Time Respiratory Rate Analysis
December 5, 2021 8:30 am 36 Cpm Abnormal
Norms:
A normal respiratory rate for adult ranges from 12-20 cycles per minute. Average is
18 cycles per minute. Breathing patterns must be regular and even in rhythm. The
normal breath sound is bronchial which is high in pitch, loud in intensity and blowing or
hollow in quantity, Broncho vesicular is moderate in pitch, moderate intensity and
combination of bronchial and vesicular, and vesicular is low in pitch, soft intensity and
gentle rustling or breezy in quality (Berman et al., 2018).
Analysis:
Patient X has abnormal respiratory status. Her respiratory rate is above normal
which is 36 rpm. Lungs were auscultated for bilateral sound, after auscultation bilateral
sounds was heard.
VIII. Circulatory Status
The table shows the blood pressure of the patient during her confinement:
Date Time Blood Pressure Analysis

15
December 5, 2021 8:35 am 75/38 mmHg Below

Normal
Date Time Pulse Rate Analysis
December 5, 2021 8:40 am 142 bpm Above

Normal
Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal
blood pressure is 120/80 mmHg. The pulse must have a regular beat and not bounding
nor weak. (Kozier & Erbs, Fundamentals of Nursing, Tenth Edition)
Analysis:
Hypotension and tachycardia are one of the common clinical S/Sx of

hemorrhagic shock. When the body compensates for volume loss it increase the heart
rate and contractility, followed by baroreceptor activation resulting in sympathetic
nervous system and peripheral vasoconstriction. As diastolic ventricular filling continues
to decline and cardiac output decreases, systolic blood pressure drops. (Armstrong,
2021).
PARAMETER COMPUTATION NORMS ANALYSIS
BMI Weight(lbs)/ Underweight: Patient X BMI

height(in)/ is in normal
Height: 62 in >18.5
height(in)x703 range level.
Weight: 121.2 lbs Normal:
121.2 ÷ 62 ÷ 62 x 703
18.5 – 24.9
BMI = 22.16
Overweight:
25.0 – 29.9
Obesity Class 1
30.0 – 34.9
Obesity Class 2
35.0 – 39.9
IX. Nutritional Status
NUTRITIONAL PARAMETER
16
Patient X rice, fish and meat. Sometimes fruits and vegetables. She eats 3 times
a day and drinks 8 glasses of water. She also drink coffee every morning.
Norms:
Maintaining healthy or ideal body weight requires a balance between the

expenditure of energy and the intake of nutrients. The normal eating pattern of a person
is minimum of three times per day depending upon the metabolic demands and needs of
the patient. (Kozier & Erb’s, 2016).
According to the Health Asian Diet Pyramid, there should be a daily intake of
rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy
products; weekly for sweets, eggs and poultry, and monthly for meat. There should be
an increase intake of a wide variety of fruits and vegetables. Include in the diet foods
higher in vitamins C and E, and omega-3 fatty acid rich foods. Fluid intake is on the
average of 8-10 glasses per day (Mohan, 2002).
Analysis:
Patient X nutritional status is normal.
X. Elimination Status:
Patient X claimed that she usually defecates once a day with semi solid
consistency, brownish in color and normal amount in elimination. She voids 4 times a
day, light yellow in color with normal amount. However, upon admission the patient’s
urine output decreases.
Norms:
The typical adult bowel movement consists of a moderate amount of formed,

brown stool that is passed without difficulty. The normal frequency of bowel elimination
varies from several stools per day to only two or three per week. Most adults experience
bowel elimination every 1 to 2 days. Normal voiding is 6 or 7 times a day with an output
of 1200 to 1500 ml a day. Urine is clear to yellowish in color. (Kozier, 2007)
Analysis:
Due to severe blood loss, Patient X urine output was decreased. Low urine output
also occurs when there is a decreased blood supply to the kidney, as occurs with
dehydration or excessive blood loss. (Stoppler, 2019)
17
XI. Reproductive Status
Patient X had her first menstrual period at the age of 14. The patient is not yet
menopausal. No menstrual period problems had arised as verbalized by the client.
Norms:
The first menstruation which is menarche occurs at an average of 9 to 17 years

old. (Pilliterri, 2010).
Analysis:
The patient’s reproductive status is normal.
XII. Sleep-rest Pattern
Patient X stated that she usually sleeps 7 to 8 hours a day. She usually sleeps at
11:00 pm and wakes at 7:00 am. She usually watches television at home during rest
hours.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic

process while rest refers to relaxation and calmness, both mental and physical. A typical
sleeper will pass through 7 to 9 hours of sleep and take a rest using home relaxation
activities such as reading, telling stories and others. (Rick Daniels, 2017)
Analysis:
Patient X has a normal and adequate sleep pattern.
XIII. State of Skin Appendages
According to Patient X she had no history of skin allergy. Upon inspection, the
patient skin is cold and clammy, pale brown in color, nail bed is pale pink, with slow
capillary refill of 3-4 seconds.
Norms:
Skin color varies from light to deep brown, pink to light pink and free from skin
diseases. Hair is resilient and evenly distributed. The nail plate is normally colorless and
has a convex curve. The angle between the fingernail and the nailbed is normally 160
degrees. (Kozier & Erb’s, 2015)
Analysis:
18
The patient has pale or grayish skin color, cold, clammy skin due to severe blood
loss caused by hemorrhagic shock. It indicates inadequate blood flow through peripheral
tissues.
BSN 4-2 GROUP 3 HEMORRHAGIC SHOCK 19
Laboratory and Diagnostic Procedures
LABORATORY & DATE INDICATION RESULTS INTERPRETATION NURSING RESPONSIBILITIES

DIAGNOSTIC ORDERED
PROCEDURE
CHEST X-ray 12/02/2021 A chest x-ray is an Showed multiple Chest X-ray showed that the chest cavity Before:
imaging test to look at right-sided rib is not outlined on each side by the white bony  Instruct the client to
the structures and fractures but a structures that represent the ribs of the chest remove any jewelry,
organs in the chest normal wall. eyeglasses, body
and to evaluate mediastinal There were multiple right sided fractures piercings, or other metal
respiratory status and contour that can cause the edges of the bone to objects.
heart size. become misaligned or displaced.  Provide appropriate
This results to flail chest which occurs when clothing. Patients are
multiple rib fractures render the chest wall instructed to remove
unstable. A flail chest usually develops when clothing from the waist
the victim has two sites of fractures in multiple up and put on an X-ray
adjacent ribs, resulting in a “floating” portion gown to wear during the
of the chest wall, paradoxically moving in and procedure.
out during respiration. During:
 Instruct the client to hold
However, normal mediastinal contourwas his breath so that the
seen which means that there areno chest stays completely
abnormalities that may help establish the
presence and determine the location of still.

pathological processes of the mediastinum or  Move into different
adjacent structures. positions in order to take
view from both the front
and the side of your
chest.
 Instruct patient to
cooperate during the
procedure. The patient
is asked to remain still
because any movement
will affect the clarity of
the image.
After:
 Note that no special
care is required
following the procedure.
 Provide comfort. If the
test is facilitated at the
bedside, reposition the
patient properly.
LABORATORY & DATE INDICATION RESULTS INTERPRETATION NURSING

DIAGNOSTIC ORDERED RESPONSIBILITIES
PROCEDURE
Pelvic x-ray 12/02/2021 Focuses specifically on Demonstrated a It was shown that there was about Before:
the area between your 3cm pubic 3cm separation of the two pubic bones in the  Remove all metallic
hips that holds many of symphyseal pubic symphysis. This is known as a objects (jewelry, pins,
your reproductive and diastasis condition that allows excess lateral or anterior buttons etc.)
digestive organs movement wherein surgical correction should  Ensure the patient is
be offered if the diastasis is more than 3 cm not pregnant
wide  Provide appropriate
clothing, instructed to
remove clothing and
put on an x-ray gown
During:
 Instruct patient to
cooperate during the
procedure
 Instruct the client to
hold his breath so that
the chest stays
completely still.
 Move into different
positions in order to
take view from both
the front and the side
of your chest.
After:
 No special care. Note
that no special care is
required following the
procedure.
 Provide comfort. If the
test is facilitated at the
bedside, reposition
the patient properly
LABORATORY & DATE INDICATION RESULTS INTERPRETATION NURSING

PROCEDURE
Focused 12/02/2021 Ultrasound examination; a positive focused It was shown that the patient’s FAST was  Remove any
Assessment with screening test for blood assessment with positive which indicates that there is jewelry from the
Sonography in around the heart sonography in an intraperitoneal fluid that have area being
Trauma (FAST) (pericardial effusion) or trauma (FAST) leaked in the patient’s abdomen located at examined.
abdominal organs exam in the right the right upper quadrant and around the  Remove some or
(hemoperitoneum) after upper quadrant and bladder due to the trauma all of your
trauma. around the bladder clothing.
 Change into a
gown.
 Explained that the
technologist can
see, hear and
speak to them at
all times.
 Position the
patient in supine
 The doctor will
discuss the
results.
LABORATORY & DATE INDICATION RESULTS NORMAL INTERPRETATION NURSING

DIAGNOSTIC ORDERED VALUE RESPONSIBILITIES
PROCEDURE
Central venous 12/02/2021 Used to assess acid-base pH of 7.28 7.35-7.45 Veins convey blood from all tissues to  Start with a modified
blood gas analysis status along with the right side of the heart before onward Allen’s test
adequacy of ventilation journey via the pulmonary artery from  If the patient is
and oxygenation among heart to the lungs. receiving oxygen
predominantly The result showed that there is a therapy, they will
critically/acutely ill decrease in central venous blood gas need to stop using it
patients. wherein this means that the venous for at least 20-30
blood is relatively lacking in oxygen and minutes
relatively rich in carbon dioxide due to  Ensure the patient is
the gaseous exchange that has in a comfortable
occurred in the capillary bed of tissue position
cells.
LABORATORY & DATE INDICATION RESULTS NORMAL VALUE INTERPRETATION NURSING

PROCEDURE
Assessment of 12/02/2021 It predicts which Score was 3 1: the penetrating Based on the ABC scoring, it was  Verify doctors
blood consumption patients are likely on mechanism (1 shown that there is presence of order
(ABC) to require a presentation point) penetrating trauma (1), systolic blood  Obtain and
massive 2: positive pressure is less than 90 mmHg (1), and record baseline
transfusion focused positive to FAST (1) for a total of 3 on vital signs
assessment presentation.  Observe for
sonography for potential
trauma (1 point) complications
3: arrival systolic  Place the client
blood pressure in fowler’s
(SBP) of 90 position
mmHg or less (1  Notify the
point), physician
4: arrival heart immediately
rate (HR) ≥ 120
beats per minute
bpm (1 point).
26
Anatomy and Physiology

Abdominal cavity and pelvic cavity
In the main, the GI tract is within the abdominal cavity. The thoracic cavity is
separated from the abdominal cavity by the diaphragm. The abdominal cavity contains
the stomach, small and large intestine, gall bladder, pancreas, and liver, and other
organs such as the spleen. There is no physical separation between the abdominal
cavity and the pelvic cavity. The
pelvic cavity contains the rectum and
other organs such as the urinary
bladder.
The abdominal and pelvic

cavities are lined with serous
membranes. The largest membrane
within the abdomen and pelvis is the
peritoneum. The peritoneum is
formed from the parietal peritoneum
and visceral peritoneum, which are
joined. The parietal peritoneum lines
the body walls and the visceral
peritoneum covers the organs. The
space between the parietal
peritoneum and the visceral
peritoneum is the peritoneal cavity, which contains fluid that enables the membranes to
slide and allows movement within the abdominal cavity. Thus mobile organs, such as the
small bowel, are able to move as the body moves. Digestive organs within the peritoneal
cavity are termed intraperitoneal, and those that are posterior to the peritoneum, such as
the pancreas and duodenum, are termed retroperitoneal organs.
Within the abdominal cavity, there are parts of the peritoneum that are folded:
this is called the mesentery. The mesentery holds parts of the digestive tract in place.
Additionally, the mesentery is a passage for blood vessels, lymphatics, and nerves to
reach the digestive viscera.
Blood Supply
The blood supply to the GI tract is via the abdominal aorta: the splanchnic
circulation. The arterial blood supply to the stomach is through the coeliac artery. The
blood drains via the hepatic portal vein. The blood supply for the liver is via the portal
circulation, with 70% of blood supply being carried to the liver from the small bowel. This
blood contains nutrients, amongst other substances. The three hepatic veins drain into
the vena cava. The other 30% of the blood supply is taken to the liver via the hepatic
artery; 25% of the cardiac output goes to the liver.
27
The blood moving through the circulatory system puts pressure on the walls of
the blood vessels. Blood pressure results from the blood flow force generated by the
pumping heart and the resistance of the blood vessel walls. When the heart contracts, it
pumps blood out through the arteries. The blood pushes against the vessel walls and
flows faster under this high pressure. When the ventricles relax, the vessel walls push
back against the decreased force. Blood flow slows down under this low pressure.
Pathophysiology (Book-Based)
Modifiable Risk Non-modifiable Risk

Factors Factors
- Environment - Age
- Lifestyle - Gender
Trauma
Hemorrhage
↓ Intravascular volume
↓ venous return to Loss of circulating blood volume ↓ Blood pressure

the heart
↓ JVP Insufficient organ perfusion

Skin Brain Heart Kidneys In all body tissues
↓ Cerebral blood ↓ Blood pressure ↓ Blood flow to

Body preferentially ↑ Lactic acid
flow → cerebral prompts kidneys
vasoconstricts production due to
hypoxia compensatory ↑
extremities to inadequate
heart rate, to
preserve central delivery of oxygen
maintain perfusion
circulation to vital
organs
Renal
Progressive ↓ in ↓ GFR
LOC Ischemia
↓ clearance of
Tachycardia lactate by the liver,
Cold, mottled kidneys, and
extremities skeletal muscle
Renal
ATN Failure Oliguria
Lactic Acidosis
LEGENDS:
Pathophysiology
Mechanism
Hemorrhagic Shock
Sign/Symptom/Lab Finding
Complications
Pathophysiology (Patient-Based)
Modifiable Risk Non-modifiable Risk

Factors Factors
- Lifestyle - Age
Trauma
Hemorrhage
Loss of circulating blood volume ↓ Blood pressure
Insufficient organ perfusion

Skin Kidneys
Heart
Cold, clammy skin Tachycardia Oliguria
LEGENDS:
Pathophysiology
Hemorrhagic Shock Mechanism
Sign/Symptom/Lab Finding
Complications
32
B. PLANNING
NURSING PROBLEM PRIORITIZATION
Prioritization Diagnosis Justification

1 Ineffective When the breathing pattern is ineffective, the body
breathing will likely not get enough oxygen to the cells.
pattern related Respiratory failure may be correlated with
to pain as variations in respiratory rate, abdominal and
evidenced by thoracic patterns. It should be managed to allow
tachypnea the body enough oxygen to the cells so that the
patient will maintain effective breathing pattern.
2 Decreased Decreased cardiac output means that there is not
cardiac output enough blood being pumped and distributed by the
related to heart to meet the needs of the body. This can be a
alterations in serious problem because the body is not getting
heart rate and enough blood and oxygen to perform normal
rhythm metabolic functions which can lead to serious
health issues, including cardiac failure. We need to
maintain the cardiac output of the patient to keep
blood pressure at the levels needed to supply
oxygen-rich blood to the brain and other vital
organs.
3 Deficient fluid A state or condition where the fluid output exceeds
volume related the fluid intake. It occurs when the body loses both
to trauma as water and electrolytes from the ECF in similar
evidenced by proportions. We need to manage vital to prevent
cool clammy potentially life-threatening hypovolemic shock.
Skin
4 Ineffective The oxygen and nutrients subsequently diffuse
tissue from the blood into the interstitial fluid and then into
perfusion the body cells. Insufficient arterial blood flow
related to causes decreased nutrition and oxygenation at the
severe blood cellular level. When diminished tissue perfusion
loss as becomes chronic, it can result in tissue or organ
evidenced by damage or death. Management is directed at
thready pulse removing vasoconstricting factors, improving
peripheral blood flow, patient’s participation, and
understanding the disease progress and its
treatment, and preventing complications.
5 Activity A state in which a person has insufficient
Intolerance physiological or psychological energy to endure or
related to complete necessary or desired daily activities.
33
Decreased Management is to improve the patient’s ability to

Tissue perform daily activities without feeling excessive
Perfusion fatigue and to maintain the patient’s respiratory
and cardiovascular functions during activities.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIO

Subjective: Ineffective breathing Within 8 hours of INDEPENDENT: After 8 hours
Upon auscultation, pattern related to appropriate nursing 1. Continuously monitor the 1. To assess the respiratory appropriate
bilateral sounds were pain as evidenced interventions, the vital signs, symmetry, and function. nursing
heard. by tachypnea patient will be able rhythm of breathing 2. To aid in breathing pattern interventions,
to establish effective pattern. and prevent aspiration of the patient wa
Objective: respiratory pattern, 2. Provide comfortable secretions. able to
- Fast breathing as evidenced by position as indicated. 3. To promote establish
- Tachycardia relaxed breathing at 3. Elevate HOB physiological/psychologic effective
normal rate and 4. Suction airway, as needed. al ease of maximal respiratory
depth. inspiration. pattern, as
DEPENDENT: 4. To clear secretions and evidenced by
5. Administer oxygen at blockage in the airway. relaxed
lowest concentration 5. For management of breathing at
indicated and prescribed underlying pulmonary normal rate a
respiratory medications. condition, respiratory depth.
distress or cyanosis.
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Decrease Within 8 hours of INDEPENDENT: INDEPENDENT: Goal partially met. After
The patient was cardiac output nursing interventions, 1. Monitor oxygen 8 hours of nursing
1. The normal oxygen
transported to the related to late the patient will be able saturation and arterial interventions, the
saturation should be
trauma bay following uncompensated to not experience blood gasses. patient was able to not
maintained at 90%
a motor cycle crash. hypovolemic further complications 2. Monitor the client’s experience further
or higher. As shock
shock brought about by central venous pressure, complications brought
progresses, aerobic
decreased cardiac pulmonary artery about by decreased
metabolism stops
Objective: output as evidenced diastolic pressure, cardiac output as
and lactic acidosis
- Conscious by: pulmonary capillary evidenced by:
occurs, resulting in
- Bilateral  Blood pressure wedge pressure, and  Blood pressure
the increased level
breath sounds within normal cardiac output/cardiac within normal
of carbon dioxide
- (+) FAST on range index. range
and decreasing pH.
the right upper (120/80mmHg) 3. Monitor for any changes (110/80mmHg)
2. CVP provides
quadrant  Strong in the level of  Strong
information on filling
around the bilateral, equal consciousness. bilateral, equal
pressures of the
bladder peripheral 4. Monitor skin color, peripheral
right side of the
- -Venous Blood pulses, and temperature, and pulses, and
heart; pulmonary
Gas testing: clear lung moisture. clear lung
artery diastolic
pH of 7.28 sound. 5. Provide electrolyte sound.
pressure and
with lactate of replacement as
pulmonary capillary
6mg/dL and a prescribed.
wedge pressure
base deficit of
reflect left-sided fluid
12 6. Monitor urine output. volumes. Cardiac

- ABC Score: 3 output provides an
Vital signs: objective number to
- BP: DEPENDENT: guide therapy.
75/38mmHg 7. Administer fluid and 3. Restlessness
- PR: 142 bpm blood replacement and anxiety are
- RR: 36 cpm therapy as prescribed. early signs of
- Temp: 35.5 ℃ cerebral hypoxia
- O2Sat: 90% while confusion and
loss of
consciousness
occur in the later
stages. Older clients
are especially
susceptible to
reduced perfusion to
vital organs.
4. Cool, pale, clammy
skin is secondary to
a compensatory
increase in
sympathetic nervous
system stimulation
and low cardiac
output and
desaturation.
5. Electrolyte
imbalance may
cause dysrhythmias
or other pathological
states.
6. The renal system
compensates for low
BP by retaining
water. Oliguria is a
classic sign of
inadequate renal
perfusion from
reduced cardiac
output.
DEPENDENT:
7. Maintaining an
adequate circulating
blood volume is a
priority.
DIAGNOSIS
Subjective: Deficient fluid Short Term: INDEPENDENT: INDEPENDENT: Goal partially met.
The patient was volume related to Within 4 hours of 1. Establish rapport. 1. To gain patient Short Term:
transported to the active fluid volume nursing interventions, 2. Monitor and record vital trust. After 4hrs of nursing
trauma bay following loss the patient will be able signs. 2. To obtain interventions, the
a motor cycle crash. to report understanding 3. Monitor Intake and baseline data patient was able to
of causative factors for output balance. 3. To ensure report understanding of
fluid volume deficit. 4. Provide frequent oral accurate picture causative factors for
Objective: care. of fluid status. fluid volume deficit.
- Conscious 4. To prevent
- Fatigue Long Term: dehydration and
DEPENDENT:
- Dry skin Within 1-3 days, the to maintain Long Term:
5. Administer intravenous
- Bilateral patient will be able to hydration status. After 1-3 days, the
fluids as prescribed.
breath sounds maintain fluid volume at patient was able to
- Cool clammy normal level AEB well maintain fluid volume
skin hydrated, intake is equal DEPENDENT: at normal level AEB
- (+) FAST on as output, and normal 5. To deliver fluids well hydrated, intake is
the right skin turgor. accurately and at equal as output, and
upper desired rates. normal skin turgor.
quadrant
around the
bladder
- Venous Blood
Gas testing:
pH of 7.28
with lactate of
6mg/dL and a
base deficit of
12
- ABC Score: 3
Vital signs:
- BP:
75/38mmHg
- PR: 142 bpm
- RR: 36 cpm
- Temp: 35.5 ℃
- 02Sat: 90%

DIAGNOSIS
Subjective: Ineffective tissue Within 8 hours of INDEPENDENT: INDEPENDENT: After 8 hours of
Upon inspection, perfusion related to rendering proper 1. Assess for signs of 1. Particular clusters of rendering proper
the patient skin is severe blood loss interventions, the decreased tissue signs and symptoms interventions, the
cold and clammy. as evidenced by patient will be able perfusion. occur with differing patient’s tissue
thready pulse to maintain 2. Assess for rapid changes causes. Evaluation perfusion was restore
Objective: maximum tissue of continued shifts in provides a baseline as evidenced by
- Pale brown perfusion to vital mental status. for future comparison. normal hemodynamic
in color organs, as 3. Assess the capillary refill. 2. Restlessness and parameters.
- Nail bed is evidenced by warm 4. Observe for pallor, anxiety are early signs
pale pink, and dry skin, cyanosis, mottling, cool of cerebral hypoxia
with slow present and strong or clammy skin. Assess while confusion and
capillary peripheral pulses, quality of every pulse. loss of consciousness
refill of 3-4 vitals within 5. Record BP readings for occur in the later
seconds patient’s normal orthostatic changes (drop stages.
- Decreased range, and of 20 mm Hg systolic BP 3. Capillary refill is slow
urine output balanced I&O. or 10 mm Hg diastolic BP and sometimes
- Vital signs with position changes. absent.
show 6. Use pulse oximetry to 4. Nonexistence of
decreased monitor oxygen peripheral pulses
BP, saturation and pulse rate. must be reported or
increased 7. Assist with position managed
heart rate changes. immediately. Systemic

and vasoconstriction
respiratory DEPENDENT: resulting from reduced
rate 8. Administer IV fluids as cardiac output may be
ordered. manifested by
9. Administer medications diminished skin
as prescribed. perfusion and loss of
pulses. Therefore,
COLLABORATIVE: assessment is
10. Review laboratory data required for constant
(ABGs, BUN, creatinine, comparisons.
electrolytes, international 5. Stable BP is needed
normalized ration, and to keep sufficient
prothrombin time or tissue perfusion.
partial thromboplastin Medication effects
time) if anticoagulants such as altered
are utilized for treatment. autonomic control,
decompensated heart
failure, reduced fluid
volume, and
vasodilation are
among many factors
potentially
jeopardizing optimal
BP.
6. Pulse oximetry is a
useful tool to detect
changes in oxygen
saturation.
7. Gently repositioning
patient from a supine
to sitting/standing
position can reduce
the risk for orthostatic
BP changes. Older
patients are more
susceptible to such
drops of pressure with
position changes.
DEPENDENT:
8. Sufficient fluid intake
maintains adequate
filling pressures and
optimized cardiac
output needed for
tissue perfusion.
9. To reduce systemic
vascular resistance
and optimize cardiac
output.
COLLABORATIVE:
10. Blood clotting studies
are being used to
conclude or make
sure that clotting
factors stay within
therapeutic levels.
Gauges of organ
perfusion or function.
Irregularities in
coagulation may
occur as an effect of
therapeutic measures.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Activity Intolerance Within 1-2 days of INDEPENDENT: Goal met. After 2 days
The patient related to nursing interventions, 1. Instruct the client to 1. Rest conserves energy of nursing intervention
complained of Decreased Tissue the patient will be take complete bed loss and improves the patient was able to
restlessness. Perfusion able to gain tolerance rest. tissue perfusion. gain tolerance to activi
Objective: to activity by 2. Meet all the daily 2. To meet the activity by performing moderat
- Fatigue performing moderate activities of daily living need of the client. activities.
- Restlessness activities. like hygiene, toilet,
- Lethargic etc. at the bed side. 3. To improve the
- Anxious 3. Assist the client to tolerance in activity.
VS taken as follows: slowly move in the
- P: 142 bpm bed and gradually sit
- T: 96 °F up in the bed or 4. To meet the activities of
- BP: 75/38 nearby chair. daily living
mmHg 4. Keep all the things independently and call
- R: 36 bpm near the bed side and for assistance, if
- Oxygen provide call bell for needed.
saturation: assistance.
90% DEPENDENT: 5. To improve tissue
5. Administer oxygen oxygenation and gain
therapy as indicated. tolerance to activity.
6. Administer IV fluids 6. To improve perfusion to

and transfuse blood organs and thereby
as prescribed. gains activity tolerance.
SOAPIE
S - Upon auscultation, bilateral sounds were heard.
O - Fast breathing, tachycardia
A - Ineffective breathing pattern related to pain as evidenced by tachypnea
P - Within 8 hours of appropriate nursing interventions, the patient will be able to establish effective respiratory pattern, as evidenced by
relaxed breathing at normal rate and depth.
I - Continuously monitor the vital signs, symmetry, and rhythm of breathing pattern.
- Provide comfortable position as indicated.

- Elevate HOB
- Suction airway, as needed.
- Administer oxygen at lowest concentration indicated and prescribed respiratory medications.
E - After 8 hours of appropriate nursing interventions, the patient was able to establish effective respiratory pattern, as evidenced by relaxed
breathing at normal rate and depth.
S- Altered heart rate/rhythm
O- Tachycardia
A- Decrease cardiac output related to Late Uncompensated Hypovolemic Shock
P- Within 8 hours of nursing interventions, the patient will be able to not experience further complications brought about by decreased
cardiac output as evidenced by blood pressure within normal range (120/80mmHg), strong bilateral, equal peripheral pulses, and clear lung
sound.
I- Monitor oxygen saturation and arterial blood gasses.
- Monitor the client’s central venous pressure, pulmonary artery diastolic pressure, pulmonary capillary wedge pressure, and
cardiac output/cardiac index.
- Monitor for any changes in the level of consciousness.
- Monitor skin color, temperature, and moisture.
- Provide electrolyte replacement as prescribed.
- Monitor urine output.
- Administer fluid and blood replacement therapy as prescribed.
E- After 8 hours of nursing interventions, the patient was able to not experience further complications brought about by decreased cardiac
output as evidenced by blood pressure within normal range (110/80mmHg), strong bilateral, equal peripheral pulses, and clear lung sound.
S- Reports of fatigue
O- Decreased skin turgor; dry skin/mucous membranes; increased body temperature
A- Deficient fluid volume related to Active Fluid Volume Loss
P- Short Term:
Within 4 hours of nursing interventions, the patient will be able to report understanding of causative factors for fluid volume deficit.
Long Term:
Within 1-3 days, the patient will be able to maintain fluid volume at normal level AEB well hydrated, intake is equal as output, and normal
skin turgor.
I- Establish rapport.
- Monitor and record vital signs.

- Monitor Intake and output balance.
- Provide frequent oral care.
- Administer intravenous fluids as prescribed.
E- Short Term:
After 4hrs of nursing interventions, the patient was able to report understanding of causative factors for fluid volume deficit.
Long Term:
After 1-3 days, the patient was able to maintain fluid volume at normal level AEB well hydrated, intake is equal as output, and normal skin tur
S - Upon inspection, the patient skin is cold and clammy.
O - Pale brown in color. Nail bed is pale pink, with slow capillary refill of 3-4 seconds. Decreased urine output
A - Ineffective tissue perfusion related to blood loss as evidenced by thready pulse.
P - Within 8 hours of rendering proper interventions, the patient will be able to maintain maximum tissue perfusion to vital organs, as
evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, and balanced I&O.
I - Assess for signs of decreased tissue perfusion.
- Assess for rapid changes of continued shifts in mental status.

- Assess the capillary refill.
- Observe for pallor, cyanosis, mottling, cool or clammy skin. Assess quality of every pulse.
- Record BP readings for orthostatic changes (drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes.
- Use pulse oximetry to monitor oxygen saturation and pulse rate.
- Assist with position changes.
- Administer IV fluids as ordered.
- Administer medications as prescribed.
- Review laboratory data (ABGs, BUN, creatinine, electrolytes, international normalized ration, and prothrombin time or partial
thromboplastin time) if anticoagulants are utilized for treatment.
E - After 8 hours of rendering proper interventions, the patient’s tissue perfusion was restored as evidenced by normal hemodynamic
parameters.
S- Fear and excessive anxiety about a task to be undertaken.
O- Absence of plan; insufficient organizational skills, unmet goals for chosen activity, insufficient resources (social, knowledge)
A- Activity Intolerance related to Decreased Tissue Perfusion
P- Within 1-2 days of nursing interventions, the patient will be able to gain tolerance to activity by performing moderate activities.
I- Instruct the client to take complete bed rest.
- Meet all the daily activities of daily living like hygiene, toilet, etc. at the bed side.
- Assist the client to slowly move in the bed and gradually sit up in the bed or nearby chair.
- Keep all the things near the bed side and provide call bell for assistance.
- Administer oxygen therapy as indicated.
- Administer IV fluids and transfuse blood as prescribed.
E- After 2 days of nursing interventions, the patient was able to gain tolerance to activity by performing moderate activities.
Generic Name Action Contraindication Side Effects Nursing
Dosage, Indication
Brand Name
Responsibilities
Route,
Classifications
Drug Study
Frequency
Generic name: Calcium 10 ml Calcium chloride Calcium chloride is CV: slowed heart Before:
Calcium
C. Implementation
IV Push  Warm solution to

Chloride (calcium chloride) contraindicated for rate, tingling,
Chloride is a
body temperature
is indicated in the cardiac resuscitation “beat waves”
calcium salt
Brand name: CaCl prior to
immediate in the presence of (rapid IV
used
administration.
treatment of ventricular fibrillation administration);
primarily to
Classification: Visually inspect

hypocalcemic or in patients with the peripheral

treat or
Antidote, Calcium Salts product for
tetany. Other risk of existing vasodilation, loc
prevent
therapy, such as digitalis toxicity. al burning, drop particulate matter
calcium
parathyroid Calcium chloride is in BP (calcium and discoloration.
deficiency.
hormone or not recommended in chloride injection) During:
Local: local Administered only

vitamin D, may the treatment of

irritation, severe by slow
be indicated asystole and
necrosis, intravenous
according to the electroven
sloughing and injection.
etiology of the dissociation.
abscess Monitor ECG if

tetany. It is also
formation (IM, calcium is infused
important to
subcutaneous faster than 2.5
institute oral
use of calcium mEq/minute; stop
calcium therapy
chloride) .
51
as soon as The infusion if the

. . (anorexia,
practicable. patient complains
nausea, vomiting,
constipation of pain or
discomfort.
abdominal pain,
After:
dry mouth, thirst,
If extravasation

polyuria),
occurs, stop
rebound
infusion
hyperacidity and
immediately and
milk-alkali
disconnect (leave
syndrome
needle/cannula in
(hypercalcemia,
place); gently
alkalosis, renal
aspirate
damage with
extravasated
calcium
solution
carbonate used
(do NOT flush the
as an antacid).
line).
Following injection

patient should
remain
recumbent for a
short time.
patient.
52
. . Report any suspected
.
adverse reactions
present to the patient.
53
Generic Name Action Contraindication Side Effects Nursing
Dosage, Indication
Brand Name
Responsibilities
Route,
Classifications
Frequency
Generic name: Tranexamic Hypersensitivity. CNS: dizziness. Before:

250-500 mg Tranexamic acid Treatment of
Active EENT: visual Check the doctors

Acid
slow IV bid- competitively excessive
thromboembolic abnormalities. order.
tid. During or inhibits activation bleeding
Brand name: Lysteda disease (e.g. CV: hypotension, Observe the 5

after of plasminogen resulting

pulmonary embolism, thromboembolism, rights of drug
operation, (via binding to from
Classification: DVT), history of thrombosis administration.
500-2500mg the kringle systemic or
Antifibronilytics venous or arterial GI: diarrhea, Do skin testing.

if necessary domain), thereby local

thrombosis (including nausea, vomiting. During:
by IV drip reducing hyperfibrinol
retinal vein or artery Administer the drug

conversion of ysis.
occlusion), at the right
plasminogen to
disseminated dosage and route
plasmin
intravascular in the right time.
(fibrinolysin), an
coagulation, Check the patency

enzyme that
fibrinolytic conditions of the IV site and
degrates fibrin
after consumption IV line.
clots, fibrinogen,
coagulopathy, history After:
and other plasma
of convulsions.
proteins, Advise patient to take
Concomitant use with
including the medication exactly as
procoagulant directed
54
. hormonal as directed.

.
. contraceptives.
Unusual change in

Severe renal
bleeding pattern
Hypersensitivity. should be
Active reported to the
thromboembolic physician.
disease (e.g.
Pulmonary embolism
DVT), history of
venous or arterial
thrombosis (including
retinal vein or artery
occlusion),
disseminated
intravascular
coagulation,
fibrinolytic conditions
after consumption
coagulopathy, history
of convulsions.
55
Concomitant use with
.
. hormonal
contraceptives.
Severe renal
Hypersensitivity.
Active
thromboembolic
disease (e.g.
Pulmonary embolism
DVT), history of
venous or arterial
thrombosis (including
retinal vein or artery
occlusion),
disseminated
intravascular
coagulation,
fibrinolytic conditions
after consumption
coagulopathy, history
of convulsions.
Concomitant use
with hormonal
56
Medical Date General description Indication/purpose Clients reaction to
management/treat performed/c the treatment
ment hanged/disc
ontinued
Red blood cells deliver oxygen to the cells and Red blood cell transfusions are Client able to get the
Packed red blood
Medical Management
12-2-21 remove carbon dioxide from the tissues. These used to treat hemorrhage and to blood product but she
cells, fresh frozen
cells are flexible and oval biconcave disks lacking improve oxygen delivery to is still bleeding
plasma, and platelets
a cell nucleus and most organelles but filled with tissues. excessively.
Fresh frozen plasma infusion
haemoglobin.
Fresh frozen plasma is a blood product made from can be used for reversal of
the liquid portion of whole blood. It is used to treat anticoagulant effects since it
conditions in which there are low blood clotting contains all of the coagulation
factors or low levels of other blood proteins. It may factors.
also be used as the replacement fluid in plasma
exchange. Platelets are tiny blood cells
that help your body form clots to
Platelets, also known as thrombocytes, are stop bleeding.
anucleated cells generated from megakaryocytic
cells in the bone marrow that, in addition to
maintaining hemostasis, play a role in the
development of non-hemostatic immunological
activities.
57
Medical Pelvic binder Date A pelvic binder is a device used to compress the Pelvic binders prevent further The client was able to
performed pelvis in people with a pelvic fracture in an effort to dislocation of fractured bone tolerate pelvic binder
12-2-21 stop bleeding. fragment and stop bleeding.
Date
discontinued
12-2-21
Cryoprecipitate A plasma-derived blood product for transfusion Prevent or control bleeding in The client was able to
12-2-21
that contains fibrinogen (factor I), factor VIII, factor patient whose own blood or tolerate
XIII, von Willebrand factor, and fibronectin.to transfused blood does not clot Cryoprecipitate.
maintaining hemostasis, play a role in the properly, resulting in excessive
development of non-hemostatic immunological bleeding.
activities.
58
Name of Date Brief description Indication/ Client’s response Nursing responsibilities
procedure performed purposes to operation
Resuscitative 12-2-21 A blocking balloon Restriction of blood Before

endovascular is inserted into the flow via the aorta, Client bleeding is • Explain the procedure to the client or to the
balloon occlusion aorta to limit which can be guardian.
reduced.
of the aorta bleeding distal to employed as a
Surgical Management
(REBOA) the balloon and temporary solution

Ensure that informed consent was obtained.
increase cardiac until definitive control
•
and cerebral of the bleeding • Inform the client that mild to moderate
oxygenation at the
discomfort is normal following the
same time.
procedure.
During
• Monitoring of cardiopulmonary status, such
as through continuous telemetry, pulse
oximetry, and patient responsiveness.
After
Closely monitor the patient's hemodynamic

status to recognize any life-threatening

changes
Patient monitoring begins with initial


resuscitation and continues after the

REBOA procedure.
59
12-2-21 Before
Pre-peritoneal pelvic Pre-peritoneal pelvic The client was able
packing (PPP) is a packing is performed to tolerate pre-
• Explain the procedure to the client or to
technique used for for controlling pelvic peritoneal pelvic
the guardian.
treating pelvic fracture hemorrhage. packing.
• Ensure that informed consent was
hemorrhage in patients
obtained.
with pelvic fractures
• Inform the client that mild to moderate
and hemodynamic
instability after a high-
procedure.
energy trauma
• Remove the pelvic binder.
representing a life-
After
threatening situation.
Before
12-2-21 External fixation of the An external fixation The client was able to Explain the procedure to the client or to
•
pelvis is indicated for device may be used tolerate pelvic external the guardian.
temporary or definitive to keep pelvic bone fixation.
• Ensure that informed consent was
stabilization of unstable stabilized and in
obtained.
pelvic ring injuries. alignment.
procedure.
After
• Review pin sites regularly and

checked for signs of inflammation, irritation,
infection or pin loosening.
Pre-peritoneal
Assessment of the pin site and surrounding

tissue. pelvic packing
To clean pin sites, Timms et al (2011)

advocate the use of chlorhexidine in alcohol
solution, except in patients with a known
sensitivity to chlorhexidine or pre-existing
skin conditions such as eczema.
Caution is required when using

chlorhexidine, as it is known to induce
hypersensitivity, generalised allergic
reactions and anaphylaxis (Medicines and
Healthcare products Regulatory Agency,
2012). Pelvic external
fixation
Medical Management
Medical Date General description Indication/purpose Clients reaction to the
management/ performed/changed/ treatment
treatment discontinued
Packed red 12-2-21 Red blood cells deliver oxygen to the cells and remove Red blood cell transfusions are Client able to get the
blood cells, carbon dioxide from the tissues. These cells are used to treat hemorrhage and blood product but she is
fresh frozen flexible and oval biconcave disks lacking a to improve oxygen delivery to still bleeding
plasma, and cell nucleus and most organelles but filled with tissues. excessively.
platelets. haemoglobin.
Fresh frozen plasma infusion
Fresh frozen plasma is a blood product made from the can be used for reversal of
liquid portion of whole blood. It is used to treat anticoagulant effects since it
conditions in which there are low blood clotting factors contains all of the coagulation
or low levels of other blood proteins. It may also be factors.
used as the replacement fluid in plasma exchange.
Platelets are tiny blood cells
Platelets, also known as thrombocytes, are anucleated that help your body form clots
cells generated from megakaryocytic cells in the bone to stop bleeding.
marrow that, in addition to maintaining hemostasis,
play a role in the development of non-hemostatic
immunological activities.
Pelvic binder Date performed A pelvic binder is a device used to compress the pelvis Pelvic binders prevent further The client was able to
in people with a pelvic fracture in an effort to stop dislocation of fractured bone tolerate pelvic binder.
12-2-21
Date discontinued bleeding. fragment and stop bleeding.
12-2-21
After Pre-peritoneal
pelvic packing and
Pelvic external fixation
is performed to the
patient.
Cryoprecipitate 12-2-21 A plasma-derived blood product for transfusion that Prevent or control bleeding in The client was able to
contains fibrinogen (factor I), factor VIII, factor XIII, von patient whose own blood or tolerate Cryoprecipitate.
Willebrand factor, and fibronectin. transfused blood does not clot
properly, resulting in excessive
bleeding.
Surgical Management
Name of Date Brief Indication/purposes Client’s response to Nursing responsibilities
procedure performed description operation
Resuscitative 12-2-21 A blocking Restriction of blood Client bleeding is Before

endovascular balloon is flow via the aorta, reduced.
• Explain the procedure to the client or to the
balloon inserted into the which can be
guardian.
occlusion of the aorta to limit employed as a
• Ensure that informed consent was obtained.
aorta (REBOA) bleeding distal temporary solution
to the balloon until definitive control
discomfort is normal following the procedure.
and increase of the bleeding.
During
cardiac and
cerebral • Monitoring of cardiopulmonary status, such as
oxygenation at through continuous telemetry, pulse oximetry,
the same time. and patient responsiveness.
After
 Closely monitor the patient's hemodynamic

status to recognize any life-threatening changes
 Patient monitoring begins with initial
resuscitation and continues after the REBOA
procedure.
Pre-peritoneal 12-2-21 Pre-peritoneal Pre-peritoneal pelvic The client was able to Before
pelvic packing pelvic packing packing is performed tolerate pre-peritoneal

(PPP) is a for controlling pelvic pelvic packing.
technique used fracture hemorrhage.
guardian.
for treating
pelvic
hemorrhage in
patients with
• Remove the pelvic binder.
pelvic fractures
and After
hemodynamic
 Monitor for any signs of bleeding.
instability after a
high-energy
trauma
representing a
life-threatening
situation.
Pelvic external 12-2-21 External fixation An external fixation The client was able to Before
fixation of the pelvis is device may be used tolerate pelvic external
indicated for to keep pelvic bone fixation.
guardian.
temporary or stabilized and in
definitive alignment.
stabilization of
unstable pelvic
ring injuries.
After
 Review pin sites regularly and checked for

signs of inflammation, irritation, infection or pin
loosening.
 Assessment of the pin site and surrounding
tissue.
 To clean pin sites, Timms et al (2011)
advocate the use of chlorhexidine in alcohol
solution, except in patients with a known
sensitivity to chlorhexidine or pre-existing skin
conditions such as eczema.
 Caution is required when using chlorhexidine,
as it is known to induce hypersensitivity,
generalised allergic reactions and anaphylaxis
(Medicines and Healthcare products
Regulatory Agency, 2012).
68
D. Evaluation
A. General Condition Upon Discharge:
Upon discharge, one of the important duty of nurses is to ensure continuity of

health and quality care as the patient leaves the hospital premises by teaching the
patient about the condition, medications, care strategies and importance of follow up
and check-ups.
Furthermore, the condition of the patient has been improving after admission,
medical management given was effective all throughout the hospitalization as
evidenced by regression of Hemoon the following x-rays, and patient’s vital signs are
within normal values. Therefore, the patient was discharged last Dec 6 2021, with a
stable condition.
B. Discharge Plan Method:
M-Medication Patient X was instructed about the medication he should continue

taking, including:
Tranexamic acid (TXA)- is a medicine that controls bleeding. It

helps your blood to clot and is used for nosebleeds and heavy
periods. If you're having a tooth taken out, using tranexamic acid
mouthwash can help stop bleeding.
E-Exercise  Instruct patient to perform passive range of motion exercises on

patient’s extremities
 Instruct patient to start walking exercise after discharge with 5-10
minutes and gradually add to your distance or to the length of time
that you walk.
T-Treatment  Instruct the patient’s parents to check the list of all the medicines
the patient takes. To take medicines exactly as directed. Make sure
they have been given instructions about the medicines and how to
take them. Do not skip doses.
 Comply with the instructions and teachings given, from medication
to follow up check-ups.
H-Health  Encouraged the patient and SO to express feelings and thoughts

Teachings about her condition and the treatment.
 Educated the patient and SO how to cope up in times of stress and
anxiety.
 Advised the patient to take medications as prescribed.
 Advised the patient to make a follow-up appointment as directed.
 Advice the patient to rest and sleep as much as possible. The
69
patient may be more tired than usual. Rest and sleep help the
patient’s body heal.
 Advice the family to maintain a clean environment and educate
patient and family members to be extra careful to avoid accidents.
 Instruct the patient to return visit on attending Physician for
scheduled follow up visit.
 Educate the patient to do not drive on his own if he is bleeding
excessively or if you have any symptoms of shock.
 Advice the patient’s parents to continue giving the medication as
prescribed.
 Advice the patient and SO to report to the physician if any
recurrence or severity of the symptoms, any adverse effect to the
medication and any development of the complications.
O- Out  The return visit of Patient O was scheduled after a week.

Patient/Follow
Up
D-Diet  Parents of Patient X was instructed to serve proper nutrition for the
patient, including Fruits and vegetables, food that are rich in iron
such as Red meat, pork and poultry, Seafood, Beans, Dark green
leafy vegetables, such as spinach. Dried fruit, such as raisins and
apricots.
 Lean meats and poultry, fish, eggs, tofu, nuts, seeds, legumes and
beans. Milk, yoghurt, cheese and their alternatives – mostly
reduced fat.
 Limit foods high in saturated fat such as biscuits, cakes, pastries,
pies, processed meats, commercial burgers, pizza, fried foods,
potato chips, crisps and other savoury snacks.
 Increase fluid intake as directed. Liquids help the patient to loosen

mucus and keeps him or her from becoming dehydrated.
S-Special Care The Physician advised the parents of Patient X to continue oral
medications as prescribed. There was no special care given and
advised.
70
III. Conclusion
Hemorrhagic stroke
Stroke is ranked as the second leading cause of death worldwide with an annual
mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high
mortality but the high morbidity also results in up to 50% of survivors being chronically
disabled. Thus stroke is a disease of immense public health importance with serious
economic and social consequences. The public health burden of stroke is set to rise
over future decades because of demographic transitions of populations, particularly in
developing countries. This paper provides an overview of stroke in the 21st century from
a public health perspective. At one year, mortality ranges from 51% to 65% depending
on the location of the hemorrhage. Half of the deaths occur in the first two days. At six
months, only 20% of patients are expected to be independent. The incidence of
hemorrhage increases exponentially with age and is higher in men than in women
The key is to keep your blood pressure under control is the best way to lower the
risk.
Surveillance of closely monitored for signs of increased pressure on the brain.

These signs include restlessness, confusion, trouble following commands, and
headache. Other measures will be taken to keep you from straining from excessive
coughing, vomiting, or lifting, or straining to pass stool or change position.
In conclusion, both general and specific objectives are attained. We learned

about the nursing interventions that should be used on this type of patient. In this area of
nursing practice, we improved our knowledge and skills.
In conclusion, both general and specific objectives are attained. We learned

about the nursing interventions that should be used on this type of patient. In this area of
nursing practice, we improved our knowledge and skills.
71
IV. Recommendation
Student Nurse
The case study is recommended for student nurses to serve as their

guideline and reference on their studies in the clinical practice in handling patient with
hemorrhagic shock they can be knowledgeable and equipped enough to render
quality nursing care to their patients.
Family Members
The case study is recommended for the patient’s family members to aid and
supply them with information for the better management of the patient’s condition.
Health Care Provider
Health Care Providers are involved in the promotion of health and disease
prevention. This study focuses on hemorrhagic shock prevention and promotion to
reduce complications and death.
72
V. Review of Related Literature

International
According to Abdu and seyoum that Stroke or cerebrovascular accident (CVA) is

a highly heterogeneous disorder with distinct subtypes, each presenting specific clinical
and epidemiological aspects .There are two main types of strokes. The most common
type of stroke is an ischemic stroke (IS) which covers 85% of the cases produced by a
blockage of blood vessels. The other less common type which covers about 15% of
cases of stroke is caused by bleeding in or around the brain which is called a
hemorrhagic stroke (HS).Distinguishing the category of stroke plays a vital role in
planning patient care. Simple clinical findings are helpful in distinguishing the type of
stroke. Also, the mean Glasgow Coma Scale (GCS) score in IS patients is higher than in
HS patients.
Acute onset of headache is the most common symptom seen in HS patients

compared to IS patients. In addition, computed tomography (CT) scan reports of IS
patients showed hypodense lesion, hyperdense artery sign, sulcus effacement, and
mass effect. However, in HS patients, a hyperdense lesion is visible. However, the
prognosis of victims depends on the type of stroke, the degree and duration of
obstruction or hemorrhage, and the extent of brain tissue death.The location of HS is an
important factor in the outcome, and this type generally has a worse prognosis than
IS.Even though simple clinical profiles help to distinguish the types of stroke, there is still
a need for diagnostic imaging . Non-contrast CT scan is the most commonly used
diagnostic imaging to distinguish two types of strokes, but it is not accessible in all
hospitals and emergency departments, which may lead to loss of treatment golden
time .Having these issues, many studies described various clinical findings especially
neurological signs and symptoms, and some of them presented formulas to distinguish
stroke types based on clinical evaluations. These characteristics including focal or
nonfocal symptoms, negative or positive symptoms, and sudden or gradual onset result
in primary segregation of stroke types in the emergency department that leads to early
diagnosis and treatment .Hemorrhagic and ischemic strokes vary according to clinical
presentations, outcome, and risk factors. The most common risk factors contributing to
the differences in manifestation and outcome of stroke types are atherosclerosis, atrial
fibrillation, and hyperlipidemia and these are by far more common in IS than in HS.
In Ethiopia, stroke is the most common neurological condition in patients

admitted to hospitals, accounting for 24% of all neurological admissions [8–10].
Moreover, the prevalence of risk factors for stroke has been increasing in Ethiopia, due
to demographic and epidemiologic shifts that affected the lifestyle of the population.
There is limited research data on the clinical presentations, risk factors, and outcomes of
stroke subtypes in Ethiopia [10] and in the study hospital as well. Recently updated
information on the IS and HS is essential for planning, implementing, and evaluating
effective and efficient preventative acute care at the health settings and for establishing
73
home rehabilitation programs for those patients that have developed disabilities.
Therefore, the objective of our investigation was to identify and compare the clinical
profile, vascular and topographic distributions, associated risk factors, and outcomes of
HS and IS among patients admitted to the medical ward of Dessie Referral Hospital
(DRH).
Local
According to Collantes et al. Stroke remains the leading cause of disability and
death in the Philippines. Evaluating the current state of stroke care, the needed
resources, and the gaps in health policies and programs is crucial to decrease stroke-
related mortality and morbidity effectively. To integrate existing national laws and
policies governing stroke and its risk factors dispersed across many general policies, the
Philippine Department of Health (DOH) institutionalized a national policy framework for
preventing and managing stroke. Despite policy reforms, government financing coverage
remains limited. In terms of access to medicines, the government launched its stroke
medicine access program (MAP) in 2016, providing more than 1,000 vials of
recombinant tissue plasminogen activator (rTPA) or alteplase subsidized to selected
government hospitals across the country. However, DOH discontinued the program due
to the lack of neuroimaging machines and organized system of care to support the
provision of the said medicine. Despite limited resources, stroke diagnostics and
treatment facilities are more concentrated in urban settings, mostly in private hospitals,
where out-of-pocket expenditures prevail. These barriers to access are also reflective of
the current state of human resource on stroke where medical specialists (e.g.,
neurologists) serve in the few tertiary and training hospitals situated in urban settings.
Meanwhile, there is no established unified national stroke registry thus, determining the
local burden of stroke remains a challenge. The lack of centralization and fragmentation
of the stroke cases reporting system leads to reliance on data from hospital records or
community-based stroke surveys, which may inaccurately depict the country's actual
stroke incidence and prevalence. Based on these gaps, specific recommendations
geared toward systems approach - governance, financing, information system, human
resources for health, and medicines were identified.
74
VI. Bibliography:
Book Based:
 Brunner and Suddarth 2018, Textbook of Medical-Surgical Nursing, 14th edition,

Vol. 1 and 2
 Fevzi Sarper Turker 2019 “Hemorrhagic Shock” retrieved from
https://www.intechopen.com/chapters/
Internet Based:
 Abdu, H., Tadese, F., & Seyoum, G. (2021). Comparison of Ischemic and
Hemorrhagic Stroke in the Medical Ward of Dessie Referral Hospital, Northeast
Ethiopia: A Retrospective Study. Neurology Research International, 2021, 1–9.
https://doi.org/10.1155/2021/9996958
 Nicholas Hooper; Tyler J. Armstrong 2021 ‘StatPearls; Hemorrhagic Shock”
retrieved from https://www.ncbi.nlm.nih.gov/books/
 Udeani, J. (2021). Hemorrhagic shock. Medscape. Retrieved December 9, 2021,
from https://emedicine.medscape.com/article/432650-overview.
 Hooper, N. (2021). Hemorrhagic shock. StatPearls [Internet]. Retrieved
December 9, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470382/.
 Tiangco, N. E. (2021). Shock in the operating room: Practice essentials, problem,
management. Shock in the Operating Room: Practice Essentials, Problem,
Management. Retrieved December 9, 2021, from
https://emedicine.medscape.com/article/2500083-overview.

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Republic of the Philippines

TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE

A Clinical Case Study

Lifestyle (Habits, Recreational, Hobbies......................................................................7

Family Health History of Illness.....................................................................................7

History of Past Illness.......................................................................................................8

History of Present Illness.................................................................................................8

Laboratory and Diagnostic Procedures.....................................................................17

Anatomy and Physiology...............................................................................................24

This patient’s assessment of blood consumption (ABC) score was 3 on presentation;

Life-threatening decreases in blood pressure often are associated with a state of

Hemorrhage is a medical emergency that is frequently encountered by

Trauma remains a leading cause of death worldwide, with approximately half of

a.) To be able to perform thorough nursing assessment.

II. NURSING PROCESS

Age: 22 years old

Address: Tarlac City

Date of Birth: March 04, 1999

Religion: Roman Catholic

Civil Status: Single

Admitting diagnosis: HEMORRHAGIC SHOCK

Lifestyle (Habits, Recreational, Hobbies)

Family Health History of Illness

History of Past Illness

History of Present Illness

Paternal Side Maternal side

Grandfather, Grandmother, Grandfather, Grandmother,

Aunt, 45 years Father, 49 Mother, 51 Aunt, 47 years

II. Mental Status

General Appearance and Behavior

Patient X shows awareness and consciousness in her surroundings by being

III. Emotional Status

IV. Sensory Perception

Date Time Temperature Analysis

December 5, 2021 8:00 am 35.5 °C Abnormal

Patient X noted to have abnormal body temperature of 35.5 °C Body temperature

VII. Respiratory Status

Date Time Respiratory Rate Analysis

December 5, 2021 8:30 am 36 Cpm Abnormal

VIII. Circulatory Status

Date Time Blood Pressure Analysis

December 5, 2021 8:35 am 75/38 mmHg Below

Date Time Pulse Rate Analysis

December 5, 2021 8:40 am 142 bpm Above

Hypotension and tachycardia are one of the common clinical S/Sx of

PARAMETER COMPUTATION NORMS ANALYSIS

BMI Weight(lbs)/ Underweight: Patient X BMI

IX. Nutritional Status

Maintaining healthy or ideal body weight requires a balance between the

Patient X nutritional status is normal.

The typical adult bowel movement consists of a moderate amount of formed,

XI. Reproductive Status

The first menstruation which is menarche occurs at an average of 9 to 17 years

The patient’s reproductive status is normal.

XII. Sleep-rest Pattern

Sleep refers to altered consciousness with general slowing of physiologic

Patient X has a normal and adequate sleep pattern.

XIII. State of Skin Appendages

Laboratory and Diagnostic Procedures

LABORATORY & DATE INDICATION RESULTS INTERPRETATION NURSING RESPONSIBILITIES

presence and determine the location of still.

LABORATORY & DATE INDICATION RESULTS INTERPRETATION NURSING