K, a 15-year-old male was involved in a motor vehicle accident and was brought to the Emergency Department. His mother w
Posted: Mon Dec 20, 2021 9:03 am
K, a 15-year-old male was involved in a motor vehicle
accident and was brought to the Emergency Department. His mother
was also involved but did not sustain any injury. K sustained an
open fracture of the right femur with significant intra-pelvic
trauma resulting in bowel injury and hemorrhage. He told his mother
that his right leg and abdomen is very painful, and feeling nausea
and dizziness. The Trauma Surgeon informed his mother that the
seriousness of his injury would require immediate blood transfusion
and an emergency operation to save his life.
The initial assessment on K by the nurse was recorded as
follows:
• Nil Past
History
• No Known
Abnormalities
• Observations: BP
70/50 mmHg, HR 125/min and regular, respiratory rate
26/min
• Skin: pale, cold
and clammy
• The right leg looks
deformed and shorter than the left leg
• Abdomen:
tenderness, distension, and diminished bowel sounds
• Pain score: right
femur 9/10; and abdomen 8/10
Identify the secondary data presented in the clinical
record.
( 8 )
accident and was brought to the Emergency Department. His mother
was also involved but did not sustain any injury. K sustained an
open fracture of the right femur with significant intra-pelvic
trauma resulting in bowel injury and hemorrhage. He told his mother
that his right leg and abdomen is very painful, and feeling nausea
and dizziness. The Trauma Surgeon informed his mother that the
seriousness of his injury would require immediate blood transfusion
and an emergency operation to save his life.
The initial assessment on K by the nurse was recorded as
follows:
• Nil Past
History
• No Known
Abnormalities
• Observations: BP
70/50 mmHg, HR 125/min and regular, respiratory rate
26/min
• Skin: pale, cold
and clammy
• The right leg looks
deformed and shorter than the left leg
• Abdomen:
tenderness, distension, and diminished bowel sounds
• Pain score: right
femur 9/10; and abdomen 8/10
Identify the secondary data presented in the clinical
record.
( 8 )