11:55 am…John, 17 years old/Camper #3 Primary Problem/Story: Arrived at the health center with a laceration of the right foot incurred while swimming in the lake

7. You’ve administered a shock with the AED. What will the voice prompts instruct you to do next?
November 13, 2019
13. Which of the following is correct technique for applying a compression wrap for a Grade II hamstring strain?
November 13, 2019

11:55 am…John, 17 years old/Camper #3 Primary Problem/Story: Arrived at the health center with a laceration of the right foot incurred while swimming in the lake

11:55 am…John, 17 years old/Camper #3 Primary Problem/Story: Arrived at the health center with a laceration of the right foot incurred while swimming in the lake. What Do You Notice? Clinical Significance: Patient hopped into the health center on one foot with no shoe on the injured foot, dripping blood. “I don’t know what I cut it on because I was in the lake at the beach swimming area.” The event occurred within the last hour. He states his last tetanus was three years ago Past Medical History: John is a 17-year-old volunteer kitchen worker who is in good health. His last recorded tetanus was five years ago. What Do You Notice? Clinical Significance: What Do You Notice? Clinical Significance: Social History/Concerns: Camp history form indicates to call either parent for communication. Cell and work phone numbers are available to the nurs What Do You Notice? Clinical Significance: Vital Signs: T: 98.2F/36.8 C (oral) P: 92 (reg) R: 20 (reg) BP: 148/84 02 sat: 96% room air What Do You Notice? Clinical Significance: P-Q-R-S-T Pain Assessment Provoking/Palliative: Onset with injury Quality: Sharp Region/Radiation: Localized at right foot laceration Severity: 7/10 Severity: 7/10 Occurred with injury Timing: What Do You Notice? Clinical Significance: Initial Nursing Assessment: Flap laceration of the right plantar surface of the foot on the ball of the foot. It is actively oozing a small amount of blood. inch (1.3 cm) x inch (1.9 cm) x 1/8 inch (0.3 cm) and is a full thickness laceration through calloused skin on foot. Copyright 2019 Keith Rischer, d/bla KeithRN.com. All Rights reserved. Complete Nursing Assessment: GENERAL APPEARANCE: Patient hopped What Do You Notice? Clinical Significance into the health center on one foot with assistance. RESP: Slightly labored NEURO: Alert & oriented, moves all four extremities SKIN: Flap laceration of the right plantar surface of the foot on the ball of the foot. It is actively oozing a small amount of blood. 1/2″ x 3/4″ x 1/8″ and is through the calloused skin 1. Identify the problem(s) impacting wellness in this setting. Interpreting relevant clinical data, what caused the problem? (Management of Care/Physiologic Adaptation) Cause/Pathophysiology: Problem: 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Cleanse wound to prevent infection Expected Outcome: What is the most likely complication(s) to anticipate based on the primary problem? What is the most important next step that the nurse needs to implement? (Reduction of Risk Potential/Physiologic Adaptation) 3. Most Likely Complication: Nurses Next Step:

 

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