OUTCOME PRESENT STATE TEST
Name: V.D
Age: 26 years old
Sex: Male
Civil Status: Single
Address: Gomez Guest House, Poblacion III, Tagbilaran City
Attending Physician: Dr. Fredegelbert I. Flor
CLIENT IN CONTEXT
Patient History:
Received patient at ER with
the chief complaint of
multiple wounds in both
upper and lower extremities
due to MVA, pain in the left
leg.
History of Present Illness:
Patient slipped while driving
2-wheeled vehicle with 1
passenger
History of Past Illness:
unremarkable
ASSESSMENT
Subjective Cues:
“That hurts. I cannot move
my left foot and cannot flex
my left elbow.” as verbalized
by the patient
Pain scale: 7/10 as 0 being
the lowest and 10 being the
highest
Objective Cues:
 Facial mask of pain
 Guarding behavior
towards his left foot and
left elbow
 Limited range of motion
of both upper and lower
extremities
 Visible laceration in left
Date Admitted: October 26, 2023 8:36PM
Chief Complaints: Motor Vehicular Accident
Admitting Diagnosis: Multiple Abrasions with 2 cm avulse
wound at left elbow area, open fracture Gustilo Type I,
complete, non-displaced, 5th phalanx, left foot all sec to MVS
Ward/Area: Emergency Room
INTERVENTIONS RATIONALE EVALUATION
Independent
 Establish rapport to patient  To gain trust and cooperation Goal met. After 6 hours of
nursing intervention, the
 Accept patient’s  Pain is subjective experience
patient was able to verbalize
description of pain. and cannot be felt by others
decrease level of pain, as
Acknowledge the pain
evidenced by (AEB):
experience and convey
acceptance of patient’s  Pain scale of 3/10 as (0
response to pain being the lowest and 10
being the highest)
 Encourage the client to  This helps alleviate anxiety.
 Less facial mask of pain
discuss problems related to Client may feel need to
relieve the traumatic
current condition
experience
 Move patient only when  This reduces muscle tension
needed slowly and or guarding behavior, which
deliberately may help minimize pain of
movement
 Personal factors can influence
 Reduce or eliminate factors
pain and pain tolerance.
that precipitate or increase
Factors that may be
pain experience (e.g., fear,
precipitating or augmenting
 elbow fatigue) pain should be reduced or
 Inflamed area as eliminated to enhance the
Socio-economic Status:
manifested by redness overall pain management
Patient verbalized no and swelling  Elicit behaviors that are  Relaxation techniques help
occupation; they visited  Overlapping 5th toe due conditioned to produce reduce skeletal muscle
Bohol with his partner for a to deformity relaxation such as deep tension which will reduce the
tour. breathing, yawning, intensity of the pain.
Nursing Diagnosis:
abdominal breathing, or
Acute Pain related to peaceful imaging
multiple wounds in both
upper and lower extremities
Organ Involved:
as evidenced by visible
laceration in left elbow and  To relieve moderately severe
Dependent pain, decrease swelling and
5th phalangeal deformity
 Administer Ketorolac pain.
Trometamol (Ketovex) as
needed for severe pain as
ordered by the doctor
5th toe phalanx, left foot
deformity. Three bones make
up the fifth toe: the distal,
middle, and proximal
phalanges. They articulate
together to make the distal
interphalangeal (DIP) joint
(DIPJ) and the PIPJ. The
proximal phalanx then
articulates with the fifth
metatarsal to make the fifth
MTPJ.
2cm avulsed wound at left
elbow area. An avulsion is a
forcible tearing off of skin or
another part of the body,
such as an ear or a finger.
Any time layers of skin have
been torn off to expose
muscles, tendons and tissue,
it is called an avulsion.

Organ Involved:
5th toe phalanx, left foot
deformity. Three bones make
up the fifth toe: the distal,
middle, and proximal
phalanges. They articulate
together to make the distal
 Relaxation techniques help
reduce skeletal muscle
 Elicit behaviors that are
tension which will reduce the
conditioned to produce
intensity of the pain.
relaxation such as deep
breathing, yawning,
abdominal breathing, or
Nursing Diagnosis: peaceful imaging
Acute Pain related to
multiple wounds in both  To relieve moderately severe
upper and lower extremities pain, decrease swelling and
as evidenced by visible pain.
Dependent
laceration in left elbow and
interphalangeal (DIP) joint
(DIPJ) and the PIPJ. The
proximal phalanx then
articulates with the fifth
metatarsal to make the fifth
MTPJ.
5th phalangeal deformity  Administer Ketorolac
Trometamol (Ketovex) as
needed for severe pain as
ordered by the doctor

2cm avulsed wound at left

elbow area. An avulsion is a
forcible tearing off of skin or
another part of the body,
such as an ear or a finger.
Any time layers of skin have
been torn off to expose
muscles, tendons and tissue,
it is called an avulsion.