[MULTIPLE INJURIES] Case Sharing

Physical Examination and Review of Systems

General Health Status
Generalized weakness
Extreme fatigue
Restlessness
Skin dry, warm to touch
Systems
Subjective Data
Head/Hair/Face
The patient may verbalize
pain in the area or proximal
to the area affected.

Pain
Pallor with cyanosis to the lips
Headache
Bleeding
Objective Data

Head

Hair

Face

Tenderness in the area of injury

Increased intracranial pressure
Pain associated with moving
Pain independent of movement or palpation
Contusions, lacerations, hematomas to the scalp
Deformity to the skull
Blood or fluid (cerebrospinal fluid) leakage from the ears or
nose
Exposed brain tissue
Soft area or depression upon palpation
Bleeding from the open bone injury
Headache
Soft tissue injuries associated with trauma - Head and neck
to cervical spine

Problem Identified
1. Acute pain
2. Impaired physical
mobility

Contusions, lacerations, hematomas to the scalp

Deformity, fractures of facial bones
Lacerations, punctures, penetrations
Bleeding
Swelling
Sunken cheekbone
6|Page

[MULTIPLE INJURIES] Case Sharing

Eyes/Ears/Nose
and Sinuses

The patient may verbalize

pain in the area or proximal
to the area affected.

Mouth and Pharynx The patient may verbalize

pain in the area or proximal
to the area affected.

Neck

Thorax/Lungs

Back

The patient may verbalize

pain in the area or proximal
to the area affected.
The patient may verbalize
chest tightness and chest
pain and difficulty of
breathing.

The patient may verbalize

Eyes
Dilated pupils
Bruising (discoloration) around the eyes
Unequal pupil size
Abnormal eye movements
Ears
Bruising (discoloration) behind the ears (mastoid process)
Blood or fluid (cerebrospinal fluid) leakage from the ears
Nose and Sinuses
Blood or fluid (cerebrospinal fluid) leakage from the nose
Fractures of the maxilla
Teeth does not align properly
Difficulty opening mouth
Numbness in the lip and chin

Lacerations, punctures, penetrations

Soft tissue injuries associated with trauma - Head and neck to
cervical spine
Increased breathing rate (tachycardia) shallow, labored, irregular
Soft tissue injuries associated with trauma - Shoulders, back or
abdomen - thoracic, lumbar
Abnormal breathing sounds, such as a crackling noise
Cough
Rib fracture
Flail chest - a segment of the thoracic cage is separated from the
rest of the chest wall
Pulmonary contusion
Tension pneumothorax
Massive hemothorax
Lacerations, punctures, penetrations

1. Acute pain
2. Body image
disturbance

1. Acute pain
2. Nutrition, altered:
less than body
requirements
3. Impaired verbal
communication
1. Acute pain

1. Impaired gas
exchange
2. Acute pain
3. Ineffective Airway
Clearance
4. Ineffective Breathing
Pattern

1. Acute pain
7|Page

[MULTIPLE INJURIES] Case Sharing

Breast and Axilla

Cardiovascular/
Peripheral Vascular

pain in the area or proximal

to the area affected.
The patient may verbalize
pain in the area or proximal
to the area affected.
The patient may verbalize
dizziness and confusion.

Lymphatic

The patient may verbalize

headache.

GIT

The patient may verbalize

pain referred up either
shoulder.

GUT/Reproductive

The patient may verbalize

pain in the area or proximal

Soft tissue injuries associated with trauma - Shoulders, back or

abdomen - thoracic, lumbar
Lacerations, punctures, penetrations

Decreased blood pressure (hypotension)

Increased pulse rate (tachycardia) weak and thready
Delayed capillary refill greater than 2 seconds
Pale, cool or warm, clammy skin
Pallor with cyanosis to the lips
Shock
Pericardial effusion
Fever
Local inflammatory reaction at the site of injury
Increased lymph formation and flow rate
Nausea and vomiting
Thirst
Intra-abdominal bleeding
Abdominal distention
Lack of bowel sounds
Jaundice
Extravasation (escape of fluid) of urine or blood under the skin)
Unusual masses (hernia)
Blood in the emesis (vomit)
Soft tissue injuries associated with trauma - Shoulders, back or
abdomen - thoracic, lumbar
Abdomen rigid when palpated
Guarding position
Bowel incontinence
Bladder trauma (perforation)
Pelvic fractures

1. Acute pain
2. Body image
disturbance
1. Ineffective tissue
perfusion
2. Decreased cardiac
output

1. Risk for infection

2. Hyperthermia
1. Acute pain
2. Bowel incontinence
3. Deficient fluid
volume
4. Nutrition, altered:
less than body
requirements

1. Acute pain
2. Altered pattern of
8|Page

[MULTIPLE INJURIES] Case Sharing

to the area affected.

Musculoskeletal

The patient may verbalize

pain along spinal column
and lower legs.

Integumentary

The patient may verbalize

pain in the area or proximal
to the area affected.
The patient may verbalize
loss of sensation in the
upper or lower extremities.

Neurologic

Suprapubic pain or tenderness

Bruising in suprapubic region
Difficulty or inability to void
Macroscopic hematuria
Pain
Tenderness in the area of injury
Swelling
Bruising (discoloration)
Exposed bone ends
Joint locked into position
Deformity or angulated or dislocation
Grating sound
Deformity to the skull
Deformity of the spine upon palpation
Soft tissue injuries associated with trauma
Bleeding from the open bone injury
Fracture
Soft tissue injuries associated with trauma - Head and neck to
cervical spine; Shoulders, back or abdomen - thoracic, lumbar;
Lower extremities - lumbar, sacral
Contusions, lacerations, hematomas to the scalp
Punctures, penetrations
Soft tissue injuries associated with trauma
Restlessness
Generalized weakness
Anxiety
Altered or decreasing mental status, unresponsive
Numbness, weakness or tingling in the extremities
Loss of sensation or paralysis below the suspected level of injury
Loss of sensation or paralysis in the upper or lower extremities
Confusion, disorientation, memory loss, temporary or permanent

urinary elimination

1. Acute pain
2. Impaired physical
mobility
3. Activity intolerance

1. Impaired skin
integrity
2. Risk for infection
1. Anxiety
2. Body image
disturbance
3. Fear

9|Page

[MULTIPLE INJURIES] Case Sharing

Endocrine

The patient may verbalized

body malaise.

Increase in circulating levels of stress hormones (glucocorticoids,

catecholamines, glucagon)

1. Fatigue

10 | P a g e