1.

Hypovolemia and decrease electrolytes related to internal bleeding

Goal and Outcomes : Intervention :

 Blood pressure, pulse,  Assess vital signs
body temperature within  Monitor parenteral fluids with
normal limits electrolytes, antibiotics and
 There are no signs of dehydration vitamins
 Good skin turgor elasticity, moist  Assess drip drops
mucous membrane  Collaboration with physicians
in administration of parenteral
fluids as indicated.
 Collaboration with doctors in
blood transfusion.
2. Acute pain related to abdominal trauma

Goals and outcomes : Intervention :

 Patient describes satisfactor
y pain control
 Patient displays improveme
nt in mood, coping.
 Facial expressions calm and
uncomfortable.
 Assess the characteristics of pain
 Give the semi fowler position
 Encourage pain management
techniques such as distraction.
 Collaboration with physician in
giving analgetik as indicated.
 Comfortable environment managemant
3. Anxiety related to critical situation

Goals and outcomes : Intervention

 Patient describes own anx  Encourage the use of successful skills
iety and coping patterns. in the past
 Client's facial expression  Encourage and provide time to express
was calm and uncomforta anxiety and fear and provide handling.
ble.  Explain the procedures and actions and
explain explanations about the diseased
 Keep the environment calm and without
stresse.
 Support from family.
4. Tissue Integrity, Impaired related to injury/trauma
Goals and Outcomes :
 No signs of infection : pus
 wound not moist and not dirty
 Normal vital signs
Intervention
 Assess skin and identification at the stage
of wound development.
 Assess location, size, color, odor, as well
as the number and type of wound fluidc.
 Monitor body temperature rise.
 Apply wound care with aseptic techniques.
Wrap wound with dry and sterile gauze, us
e paper plaster.
 Debridement.
 After debridement, replace the dressing as
needed.g. Collaboration with physicians in
the provision of antibiotics as indicated.
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