ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM
Subjective: Vascular trauma occurs when a STO: Monitor vital signs. Observe Tachycardia, tachypnea, and BP STO:
“Tuwing sinasalinan sya ng dugo blood vessel sustains either a blunt After 30 mins - 2 hours, the changes in cardiac rhythm. changes are associated with (Goal met)
nilalagnat talaga sya.” injury or a penetrating injury. patient and significant other will progressing hypoxemia and
Vascular trauma occurs when an be able to: acidosis. Within 30 mins – 2hrs or nursing
Objective: artery (a blood vessel that carries a. identify signs/symptoms to intervention, the patient and
Temp : 39 C blood away from the heart) or a report to healthcare provider significant other will be able to:
Skin warm to touch vein (a blood vessel that carries
Palpable venous cord or
a. identified signs/symptoms to
Irritable blood back to the heart) sustains an Assessed peripheral IV site, when purulent drainage require
LTO: report to healthcare provider
Discomfort injury. one already in place, to determine immediate intervention.
After 48 – 72 hours, patient will
Restlessness potential for complications. LTO:
be able to:
Weakness (Goal met)
a. be free of signs/symptoms
Chills Identified extremities or sites that Edema can inhibit successful IV
Profuse diaphoresis
associated with venipuncture, have impaired circulation or injury. cannulation and potentiate risk Within 48 – 72 hours of nursing
infusion solution, or local
infection for infiltration. intervention, patient will be able
to:
Nursing Diagnosis: a. be free of signs/symptoms
Routine replacement is thought
Risk for vascular trauma related to Changed IV site when swelling is associated with venipuncture,
to reduce the risk of phlebitis
insertion site as evidenced by noted.
and bloodstream infection. infusion solution, or local
swelling and redness.
infection
Fragile and scarred vein is not
Inspected and palpated chosen effective for infusion.
veins to determine size and
condition. To relieve pain and decrease
tension.
Provided nonpharmacological pain
management such as massaging the
arms.

Observed IV site on a regular basis. Check your IV insertion site

every day for signs of infection,
such as redness or swelling.

Instructed s/o to report any To problem-solve issues that

discomfort and any untoward signs arise with IV site.
and symptoms.