A 25-year-old male construction worker with a superficial laceration on the left forearm is being treated. Which initial step is most appropriate in providing wound care for this patient?

B) Clean the wound with normal saline

A) Apply a sterile dressing immediately

B) Clean the wound with normal saline

C) Administer tetanus prophylaxis

A 25-year-old male construction worker presents with a 3 cm superficial laceration on his left forearm. The wound is clean with minimal bleeding and no signs of infection. What is the most appropriate initial action by the nurse?

B) Clean the wound with saline and apply a sterile dressing

A) Apply a tourniquet above the wound

B) Clean the wound with saline and apply a sterile dressing

C) Administer antibiotics prophylactically

D) Suture the wound immediately

What is the most important sign the nursing team should monitor to ensure the wound is healing properly and not developing an infection?

C) Absence of new symptoms like increased pain or discharge

D) Patient's adherence to wound care instructions

After a successful wound care intervention, the nursing team plans for the patient's discharge. Which of the following is the most important instruction to give the patient regarding signs that require immediate medical attention?

B) Slight redness around the wound

Which of the following findings indicates that the patient's wound is healing properly?

C) Edges showing signs of epithelialization

A) Presence of swelling and discharge

C) Edges showing signs of epithelialization

D) Increased pain level at the wound site

What is the primary indication that the patient's wound is healing properly following discharge?

B) The wound edges show signs of epithelialization

C) The patient received a tetanus booster

D) The patient's vital signs are stable

Which of the following interventions is most appropriate for managing mild itching due to a suspected allergic reaction to wound dressing adhesive?

B) Switch to a hypoallergenic dressing and apply a topical antihistamine

A) Apply a thick layer of corticosteroid cream directly on the wound

B) Switch to a hypoallergenic dressing and apply a topical antihistamine

C) Increase the frequency of wound dressing changes

D) Apply ice directly to the wound site to reduce itching

During a follow-up visit, a patient reports that their itching has resolved after switching to a hypoallergenic dressing and using a topical antihistamine. What is the most likely reason for this improvement?

A) The hypoallergenic dressing reduced the allergic response.

B) The patient was prescribed oral antibiotics.

C) The patient's wound was surgically debrided.

D) The patient increased their physical activity.

What is the most likely reason for the resolution of the patient's itching symptoms?

A) The use of hypoallergenic dressing and topical antihistamine

B) An increase in the patient's hydration and nutrition

C) The natural healing process of the wound

D) A decrease in the patient's activity level

trauma - Nursing Case Study

Pathophysiology

• Primary mechanism: Tissue Damage - Trauma causes direct damage to tissues and cells, leading to bleeding, inflammation, and potential infection. The body initiates a healing response, which includes clot formation and immune activation.

• Secondary mechanism: Shock - Severe trauma can result in shock, where blood flow and oxygen delivery to vital organs are compromised. This can lead to organ dysfunction and requires immediate intervention to restore circulation and support vital functions.

• Key complication: Inflammatory Response - The body's response to injury can become excessive, resulting in swelling and further tissue damage. Nurses must monitor for signs of systemic inflammation, which can complicate recovery and lead to conditions such as acute respiratory distress syndrome (ARDS) if not managed effectively.

Patient Profile

Demographics:

25-year-old male, construction worker

History:

• Key past medical history: No significant medical history

• Current medications: None

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Minor laceration on left forearm

• Key symptoms: Mild pain and swelling, no signs of infection

• Vital signs: Blood pressure 120/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon further assessment, the nursing team noted that the 25-year-old male construction worker presented with a superficial laceration approximately 3 cm in length on his left forearm. The wound edges were clean with minimal bleeding observed. No foreign bodies were embedded in the wound, and the surrounding skin appeared intact with mild erythema. The patient reported mild pain at the site, rating it 3 out of 10 on the pain scale, which was consistent with the inflammation expected from minor tissue trauma. There were no signs of infection, such as purulent discharge or increased warmth.

The nursing team conducted a focused physical examination to rule out any additional injuries. The patient's range of motion in the left arm was preserved, and there was no evidence of neurovascular compromise, as sensation and capillary refill were normal. The patient's vital signs remained stable with blood pressure at 120/80 mmHg, heart rate at 78 bpm, respiratory rate at 16 breaths per minute, and oxygen saturation at 98% on room air. These findings indicated that the patient was hemodynamically stable and not experiencing any systemic inflammatory response at this time.

In light of these findings, the nursing team decided to proceed with wound care, including cleaning the laceration with saline, applying a sterile dressing, and providing tetanus prophylaxis as the patient was unsure of his last booster. Education on signs of infection and wound care at home was provided to the patient. The team planned to monitor for any changes in the wound or systemic symptoms that might indicate complications, ensuring a smooth recovery process.

Section 2

Response to Interventions:

Following the initial wound care and patient education, the nursing team monitored the patient for any signs of improvement or potential complications. Over the next 24 hours, the patient reported a reduction in pain, now rating it at 1 out of 10. The erythema around the wound had diminished slightly, and the patient noted no new symptoms such as increased pain, swelling, or discharge. The sterile dressing was changed as per protocol, and the wound appeared to be healing well with no signs of infection.

The patient's vital signs remained stable during routine checks, with blood pressure maintained at 118/76 mmHg, heart rate at 76 bpm, respiratory rate at 16 breaths per minute, and oxygen saturation consistently at 98% on room air. These stable vital signs further indicated that the patient was not experiencing any systemic complications. The patient expressed understanding of the wound care instructions and was adhering to the prescribed regimen.

Given the positive response to the interventions and the absence of complications, the nursing team felt confident in planning for the patient's discharge. They emphasized the importance of continuing wound care at home and advised the patient to seek medical attention if he noticed any signs of infection, such as increased redness, warmth, swelling, or discharge. The patient was also reminded to follow up with his primary care provider for a tetanus booster if needed and to ensure proper healing of the wound. With clear instructions and a strong support system, the patient was set on a path toward full recovery.

Section 3

After the patient was discharged, he continued to follow the wound care instructions diligently at home. During a follow-up visit a week later, the nursing team conducted a thorough assessment to evaluate the progress of the wound healing process. Upon examination, the wound appeared clean, with the edges showing signs of epithelialization, indicating healthy tissue regeneration. The patient reported that his pain levels had remained low, consistently rating it at 0 out of 10 since the previous discharge. The erythema had further diminished, and there was no swelling or discharge present.

Vital signs were once again stable, with a blood pressure reading of 116/78 mmHg, a heart rate of 74 bpm, a respiratory rate of 16 breaths per minute, and an oxygen saturation of 98% on room air. These findings reassured the nursing team that the patient continued to experience no systemic complications. Additionally, the patient had adhered to the advice to obtain a tetanus booster, which was confirmed in his medical records. His compliance with the wound care regimen and follow-up instructions demonstrated his commitment to recovery.

As the nursing team reviewed the patient's progress, they emphasized the importance of ongoing monitoring for any subtle changes that could indicate complications, such as infection or delayed healing. They encouraged the patient to continue attending his scheduled follow-ups to ensure the wound healed completely and to promptly address any concerns that might arise. With the patient demonstrating a strong understanding of his care plan and showing significant improvement, the nursing team was optimistic about his continued recovery and eventual return to full health.

Section 4

During the next scheduled follow-up visit two weeks after discharge, the nursing team conducted another comprehensive assessment to ensure that the wound healing process remained on track. Upon inspection, the wound continued to show positive signs of healing, with increased epithelialization and no signs of infection. However, the patient reported a new, mild itching sensation around the wound site, which he rated as a 2 out of 10 in terms of discomfort. This prompted the nursing team to consider the possibility of a minor allergic reaction to the adhesive in the bandages being used for the wound dressing.

The vital signs remained stable, reaffirming the absence of systemic complications: blood pressure was 118/76 mmHg, heart rate was 72 bpm, respiratory rate was 16 breaths per minute, and oxygen saturation was steady at 98% on room air. Laboratory results from a routine blood test done earlier showed a slight increase in eosinophil levels, which could correlate with an allergic response. To address the itching and potential sensitivity, the nursing team recommended switching to a hypoallergenic dressing and applying a thin layer of a topical antihistamine around the affected area.

The patient was advised to monitor for any escalation in symptoms or the appearance of a rash and to report these immediately. He was also reminded of the importance of maintaining proper hydration and nutrition to support the body's healing processes. The nursing team scheduled another follow-up visit in a week to reassess the wound and ensure that the new dressing approach was effective. With these adjustments, they remained optimistic about the patient’s recovery trajectory, looking forward to continued improvements and the mitigation of this minor complication.

Section 5

During the follow-up visit one week later, the nursing team conducted a thorough reassessment of the patient's condition to evaluate the effectiveness of the recent interventions. The patient reported that the mild itching sensation had significantly decreased since switching to the hypoallergenic dressing and applying the topical antihistamine. He rated the itching as 0 out of 10, indicating complete resolution of that particular symptom. Upon inspection, the wound showed further epithelialization with no signs of infection or additional irritation, confirming that the new dressing approach was appropriate and effective.

Vital signs remained stable, with blood pressure at 116/74 mmHg, heart rate at 70 bpm, respiratory rate at 16 breaths per minute, and oxygen saturation at 98% on room air. These findings, along with the resolution of the itching, suggested a positive response to the interventions. The nursing team also reviewed the patient's laboratory results, noting that eosinophil levels had returned to normal, further supporting the hypothesis of a resolved allergic reaction.

The nursing team was pleased with the patient's progress and encouraged him to continue adhering to the recommended care practices, including maintaining adequate hydration and nutrition. They scheduled another follow-up visit in two weeks to ensure the continued healing of the wound and to monitor for any other potential issues. With the patient's condition steadily improving and no new complications arising, the team was confident in the patient's recovery trajectory and the effectiveness of the current care plan.