Answer:
A client arrived in the emergency department with a sharp object penetrating the diaphragm. This can be a serious injury, however, the cardinal signs and symptoms of an impaired gas exchange should identify as a priority.
The nurse would first assess the airway by observing for any respiratory distress or inappropriate cough. Other potential indicators are tingling/tingling sensation on the tongue and lips, inability to swallow, hoarseness, or voice changes.
Explanation:
The nurse could identify the priority nursing diagnosis as an abnormal breathing pattern. The nurse may need to alert the physician that this type of injury will cause impaired gas exchange, which can affect vital organs in the body.
The priority of nursing care is to stop the bleeding and assess for any underlying injuries. A nursing diagnosis of pain and anxiety might be appropriate if the client was found to be in severe pain, but not stress related. Since we know that diaphragm injuries can cause impeded gas exchange, it would make sense if this client exhibited signs of impaired gas exchange and had shortness of breath after the brief attempt at identifying their wound.
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