Description
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Patient name: JR, 14years old male, No allergies
Primary concern: Gun shot wound
Hx; Gun shot injury in left buttock
Vitals signs: RR 21, pulse 61, BP: 128/71
SPO2 100 on the right finger
Heart: clear heart beats S1 S2 heard clearly
Lungs all clear all extremities
Patient complain of abdominal pain rate pain 9/10
Objective assessment: Neuro assessment: GCS 15, patient was alert and oriented to , pupils are equal,
round and reactive to light and accommodation. Skin is appropriate to ethnicity.
Vitals signs: RR 21, pulse 61, BP: 128/71
SPO2 100 on the right finger
Heart: clear heart beats S1 S2 heard clearly
Intervention: Given patient morphine 600mg every 4-6 hours PRN giving with apple juice. Reassess the
client but he was sleeping.
Change underwear soak with blood, change sheet
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