Mini Case

Presentation:
Abrasion

Princess Grace A. Pechon, SN

 PATIENT’ S DATA
BASE:
 Gender: Male
 Age: 29 yrs old
 Admission date and time: 1/22/18- 1:00 PM
 History of present illness:
Abrasions @ Right forearm, anterior chest due to a vehicular
accident @ Makar road last January 21, 2018.
 Chief Complaints: VA
 Diagnosis:
Abrasion Right forearm, anterior chest
 Introduction
A wound is a type of injury in which skin is torn, cut or punctured
(an open wound), or where blunt force trauma causes a contusion (a
closed wound). In pathology, it specifically refers to a sharp injury
which damages the dermis of the skin.
An abrasion is a wound caused by superficial damage to the skin, no
deeper than the epidermis. It is less severe than a laceration, and bleeding,
if present, is minimal. Mild abrasions, also known as grazes or scrapes, do
not scar or bleed, but deep abrasions may lead to the formation of scar
tissue. A more traumatic abrasion that removes all layers of skin is called
an avulsion.
Abrasion injuries most commonly occur when exposed skin comes
into moving contact with a rough surface, causing a grinding or rubbing
away of the upper layers of the epidermis. (Kidd, P. S., Sturt, P. A., & Fultz,
J. 2000)
 Etiology and
Methodology
Most often simply a minor injury, an abrasion is caused when the
skin comes into contact with any rough or rigged surface, almost
always with some sort of movement. Whether running and falling or
a moving object collides, if there is damage to outer layers of the skin,
then it is an abrasion.
Most often with abrasions there is little to no bleeding involved
and the chances of scarring is minimal. An abrasion isn’t as serious as
a laceration, in which a deeper wound occurs and there is typically
much more bleeding involved. However, some abrasions can be very
serious, and these occur when multiple layers of skin are damaged or
removed. In situations like these, scarring is almost certain.
Etiology and
Methodology

Run-of-the-mill abrasions are most commonly referred to as “burns,” as in

rug burns, rope burns, and carpet burns. These types of abrasions can be treated
by simply cleaning the wounds and using a topical cream or ointment like
Neosporin to help it heal quickly and to eliminate or at least minimize any pain
or stinging sensations. More serious abrasions will most often require treatments
including dressing the wounds and antibiotics.
As with most wounds, the healing time of abrasions will vary based on the
severity of the injury and the methods of treatment. A mild, treated abrasion
could take merely a few days to heal, whereas an untreated wound could take
more than a week. The deeper the wound, the longer it will take to heal that is
why cleaning the wound in a timely manner and using the right antibiotics is of
the utmost necessity. Otherwise the wound could become infected and require
further medical attention.
Wound Abrasions
 Objectives of the
Study
General Objective:
 Conduct assessment and physical examination utilizing therapeutic
communication;
 Discuss drugs administered and its associated nursing responsibilities;
 Enumerate obtained initial database written on the client’s chart;
 Discuss the anatomy and physiology of the system where the diagnosis
belongs;
 Enumerate abnormal diagnostic and laboratory findings;
 Discuss actual pathophysiology of the patient’s case;
 Construct nursing care plan made for the client in response to the needs
manifested by the client
Forearm anatomy
Anterior chest
anatomy
Pathophysiology of
Wound
 Laboratory Result

Complete Blood Count Actual Result Normal Values

WBC 8.23 4.5000-11.5000x10^g/l
Segmenters 0.55 0.5000-0.7000
Lymphocyte 0.31 0.1800-0.4200
Monocyte 0.08 0.0200-0.1100
Eosinophils 0.06 0.0100-0.0300
Basophils 0.00 0.0000-0.0200
Hematocrit 0.48 0.4000-0.5400/L
Hemoglobin 161 140.0000-180.0000 g/l
Platelet Count 167 150.0000-
450.0000x10^g/l
RBC count 5.14 4.6000-6.0000x10^12/l
Urinalysis

Color Yellow

Reaction 6.0

Specific Gravity 1.030

Transparency Clear

Sugar and Albumin Negative

 Doctors Order

Janurary 22, 2018 -NPO except medication

-CBC Blood type
Chest X-ray
-LR 2 bottles
-Cefuroxime 750mg IV every 8 hrs
-Ceflecoxin 200 mg 1cap OD
January 23, 2018 -May have DAT
8: 05am
Dr. Padua
 Drug Study
Drug Name: Cefuroxime
Drug classification: Antibiotic
Dose: 750 mg IV q 8 hours
Indication: Serious lower respiratory tract infections, UTI,
skin or skin-suture infections, meningtis and gonorrhea
Mode of Action: Inhibits cell-wall synthesis, promoting
osmotic instability: usually bactericidal
Side effects: nausea, vomiting, diarrhea and GI
disturbances
Nursing Considerations:
Assessment
History: Hepatic and renal impairment, lactation, pregnancy
Physical: Skin status, LFTs, renal function tests, culture of affected area, sensitivity tests
Interventions
Culture infection, and arrange for sensitivity tests before and during therapy if expected response is not
seen
Have vitamin K available in case hypoprothrombinemia occurs.
Discontinue if hypersensitivity reaction occurs.
Teaching points
Avoid alcohol while taking this drug and for 3 days after because severe reactions often occur.
May experience these side effects: Stomach upset or diarrhea.
Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site.
 Drug Study
Drug Name: Celecoxib
Drug Classification:
NSAID
Analgesic (nonopioid)
Dose: 200 mg/ 1cap/ OD
Indication: to relieve signs and symptoms of;
osteoarthritis, RA, acute pain and primary
dysmenorrhea
Mode of Action: Thought to inhibit prostaglandin
synthesis, impeding cyclooxygenerase-2, to produce
anti-inflammatory analgesics and antipyretic effect
Nursing considerations:
Assessment
History: Renal impairment, impaired hearing, allergies, hepatic and CV conditions, lactation, pregnancy
Physical: Skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation,
peripheral sensation; P, edema; R, adventitious sounds; liver evaluation; CBC, LFTs, renal function tests;
serum electrolytes
Interventions
BLACK BOX WARNING: Be aware that patient may be at increased risk for CV events, GI bleeding;
monitor accordingly.
Administer drug with food or after meals if GI upset occurs.
Establish safety measures if CNS, visual disturbances occur.
Take drug with food or meals if GI upset occurs.
Take only the prescribed dosage; do not increase dosage
 Prioritization of
Problems
Rank Problem

1st Impaired skin integrity related presence of wound as

manifested by itching in affected parts and
presence of wounds @ Right forearm and anterior
chest
2nd Acute pain related to presence of wound as
manifested by pain scale of 4 out of 10, facial
grimacing and guarding behavior

3rd Disturbed sleep pattern related to environmental

barrier secondary to room temperature and
unfamiliar settings as manifested by difficulty in
initiating sleep with unintentional awakening and
feeling unrested
 Nursing Care Plan
Assessment
Subjective Cues:
Nagsamad samad ko maam
tungod kay na disgrasya mi,
katul katul pud siya maam
Objectives:
•Pain scale of 4 out of 10
•Reports itching is in
affected parts
•Wounds noted ate R
forearm and anterior chest
•Initial VS;
T=36.4 C
P=70 bpm
R=18 cpm
BP=110/70 mmHg
Health Nursing Desired Intervention Rationale Evaluation
Pattern Diagnosis Outcomes
N Impaired After 8 hours of Independent: •Assessment of pain Goal met,
U Skin Integrity experience is the
T
nursing After 8 hours
related to 1.)Assess pain first step in planning
R intervention characteristics:Quali
of nursing
presence of pain management
I patient will be ty (e.g., burning, intervention
T wound as strategies. The most
manifested able to display sharp, shooting)
reliable source of the patient
I
O by itching in timely healing of Severity (scale of 0 information about was able to
or no pain to 10 or
N afffected wounds without most severe pain) the pain is the display timely
A parts and complications Location (anatomical patient. Descriptive healing of
L
-
presence of description) scales such as a wounds
wounds @ Onset (gradual or visual analogue can
M sudden)
without
E Right be utilized to Complication
Duration (how long;
T forearm and distinguish the
intermittent or as evidenced
A anterior continuous) degree of pain.
B chest by no wound
Precipitating or
O relieving factors discharges, no
L inflammation
I and no redness.
Assessment Health Pattern Nursing Desired Intervention Rationale Evaluation
Diagnosis Outcomes
2.) Assess for • An increase in
signs and BP, HR, and
symptoms temperature may
be present in a
relating to pain.
patient with acute
3.) Inspect pain
surrounding skin • To assess for
for erythema or complications
inflammation and infection.
and note odor
4.) Inspect skin • To promote
on daily basis, optimal wound
describing healing.
wound
characteristics
and changes
observed.
Assessment Health Pattern Nursing Desired Intervention Rationale Evaluation
Diagnosis Outcomes

5.) Periodically •To monitor

measure wound progress of
and observe for wound healing
complications
like infection and
dehiscence.
6.) Keep the area • To assist body’s
clean and dry, natural process
carefully dress of repair.
wounds prevent
infection, and
stimulate
circulation to
surrounding
areas.
7.) Use •To protect the
appropriate wound and
barrier dressings surrounding
and wound tissues.
coverings.
Assessment Health Pattern Nursing Desired Intervention Rationale Evaluation
Diagnosis Outcomes
8.) Remove wet •Moisture
and wrinkled potentiates skin
dressing/ linens breakdown
promptly.
9.) Provide •To aid in skin
optimum and tissue
nutrition. healing and to
maintain
general good
health.
Dependent:
10.) Administer •To relieve pain
prescribed pain and prevent
medications, infection and
antibiotics and complications.
other
medications