Assessment
Percussion:
- No specific information regarding percussion is provided in the patient documentation. Percussion is typically performed to assess the presence of tympani (a drum-like sound) or dullness (a muffled sound) over different areas of the body.
- Tympani is expected to be predominant over hollow organs.
- Dullness is expected to be heard over solid organs such as the liver and spleen.
Auscultation:
- Bowel sounds: Bowel sounds are described as normative, indicating that the frequency and intensity of bowel sounds are within the expected range.
- Breath sounds: Breath sounds are clear, suggesting no abnormal respiratory sounds. However, diminished sounds at the base of the lungs indicate a reduction in air entry.
NR 226 RUA Fundamentals Patient Care
Neurological Exam:
- Orientation: The patient is oriented to person, place, and time, indicating intact cognitive functioning.
- Cranial nerves: Gross assessment of cranial nerves II-XII reveals their intact function.
- Reflexes: Reflexes in the upper extremities are graded as 2+, indicating normal responses. However, lower extremity reflexes are absent, which can be expected in a patient with paraplegia.
- Motor and sensory function: The patient cannot move her lower extremities, indicating paralysis. Additionally, she has no sensation of sharpness, dullness, or temperature from the nipple line (around the level of the T4 dermatome) and below. This suggests a loss of sensory perception in the lower body, which is consistent with the spinal cord infarction she experienced.
Pathophysiology
Functional Changes:
The individual experiences a decrease in strength to move their fractured extremity. This is due to the disruption of the bone structure and surrounding tissues.
An inflammatory response occurs, leading to increased pain and blood flow to the affected area. This can result in redness and warmth unless blood flow is compromised due to the fracture type.
Inability to Support the Body:
In the case of D.M. and his T4-T5 fracture, his body cannot bear the weight of his upper half, leading to an inability to walk.
The fracture in this location affects the body’s support system, making it unable to bear the load adequately.
The burst fracture also impacts the nerves associated with T4 and T5. This disrupts the pathway for nerve impulses, making it challenging for the brain to transmit signals necessary for body movement.
NR 226 RUA Fundamentals Patient Care
Reflection
Communication
Effective communication strategies will be employed to ensure optimal patient care:
Active listening will be practiced to understand D.M.’s concerns and needs, promoting a therapeutic relationship.
Non-verbal communication, such as maintaining eye contact and using appropriate facial expressions, will enhance understanding and empathy.
Cultural awareness will be demonstrated to respect and accommodate D.M.’s cultural background, beliefs, and preferences.
Patient education will be tailored to his preferred learning style to enhance comprehension and engagement.
Safety/Infection Control
Safety Concerns:
D.M. is at risk for several safety issues and complications:
Deep Vein Thrombosis (DVT): Measures will be taken to prevent blood clot formation, such as regular leg exercises, proper positioning, and possibly compression stockings.
Muscle atrophy: Regular range-of-motion exercises and physical therapy will be implemented to prevent muscle weakness and loss of function in the lower extremities.
Decreased healing: Appropriate wound care and monitoring will be essential to promote optimal healing of injuries or surgical sites.
Pressure ulcers: Frequent repositioning, proper padding, and skin inspection will be performed to minimize the risk of pressure ulcers, especially since D.M. is bedbound.
Psychological adjustment: D.M.’s new diagnosis of paraplegia may impact his mental well-being. Emotional support and counseling will assist with coping and maintaining his self-care abilities.
Infection Control:
Stringent infection control measures will be implemented:
Hand hygiene will be practiced diligently by all healthcare providers.
Gloves will be worn when appropriate, especially during procedures involving bodily fluids.
Regular bathing and hygiene measures will be provided to maintain cleanliness and prevent infection.
Foley catheter care will include cleaning at least once per shift and when soiled and emptying the catheter every 4 hours to prevent urinary stasis and potential infections.
Wound care will involve monitoring the incision site for signs of infection, such as redness, swelling, or abnormal drainage. Dressings will be changed promptly when soiled, and the nurse will assess the incision site daily to ensure proper healing and the absence of complications.
NR 226 RUA Fundamentals Patient Care
Reference
Crawford, A. & Harris, H (2016). Caring for adults with impaired physical mobility. Nursing: December 2016 – 46(12), p. 36-41. doi 10.1097/01.NURSE.0000504674.19099.1d Santos, C., Almeida, M., & Lucena, A. (2016). The Nursing Diagnosis of risk for pressure ulcer: content validation. Revista Latino-Americana de Enfermagem, 24, e2693.
https://doi.org/10.1590/1518-8345.0782.2693
Suarni, L., Nurjannah, I., & Apriyani, H. (2015). Nursing and collaborative diagnoses on perioperative with and without using six steps of diagnostic reasoning methods. Int J Res Med Sci: 3(Suppl 1): S97-103.
