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Case study of spinal cord injury
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Case study of spinal cord injury
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NURSING CARE PLAN Patient’s Initials: CH Student’s Name: PFC Kohler Medical Diagnosis: Spine-HALO Application Date:10/12/2016 1. PROBLEM 2. GOAL/ OUTCOME 3. INTERVENTIONS 4. RATIONALE 5. EVALUATION Dx: Activity intolerance R/T: inefficient work of breathing AEB: Shortness of breath during and after ADL’s SUB Mother reports “She cannot walk very far before needing her wheel chair”. OBJ SOB during ambulation Sa02 – 94% Respiratory Rate - 35 ST 1:. Patient will display adequate gas exchange as evidence by SaO2 values and respiratory rate consistent with baseline. LT 1: Patient will be able to maintain ADL’s without displaying excessive wob by time of discharge 1)Nurse will monitor …show more content…
LT 1: Goal Not Met Patient not yet discharged form hospital. 6. DISCHARGE PLANNING/PATIENT TEACHING NEEDS 1)Recognize signs and symptoms of respiratory distress that must be reported to physician 2)Effectively demonstrate understanding of nan pharmacological techniques used to manage shortness of breath 3)Patient will demonstrate understanding of the importance of participating in activities 4)Patient and family will verbalize understanding of the importance of following the therapeutic plan for improving activity tolerance. STUDENT NURSING CARE PLAN Patient’s Initials:KH Student’s Name: PFC Kohler Medical Diagnosis: Spine-HALO Application Date: 10/13/2016 1. PROBLEM 2. GOAL/ OUTCOME 3. INTERVENTIONS 4. RATIONALE 5. EVALUATION Dx: Risk for impaired skin integrity R/T: Mechanical interruption of skin and tissue AEB: SUB Pain score 3/10 OBJ ST 1:. Patient will report any pain or discomfort during course of 12hr
Ascertaining the adequacy of gaseous exchange is the major purpose of the respiratory assessment. The components of respiratory assessment comprises of rate, rhythm, quality of breathing, degree of effort, cough, skin colour, deformities and mental status (Moore, 2007). RR is a primary indicator among other components that assists health professionals to record the baseline findings of current ventilatory functions and to identify physiological respiratory deterioration. For instance, increased RR (tachypnoea) and tidal volume indicate the body’s attempt to correct hypoxaemia and hypercapnia (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). The inclusive use of a respiratory assessment on a patient could lead to numerous potential benefits. Firstly, initial findings of respiratory assessment reveals baseline data of patient’s respiratory functions. Secondly, if the patient is on respiratory medication such as salbutamol and ipratropium bromide, the respiratory assessment enables nurses to measure the effectiveness of medications and patient’s compliance towards those medications (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). Thirdly, it facilitates early identification of respiratory complications and it has the potential to reduce the risk of significant clinical
A cardiac assessment: Listen to heart sounds listening for extra heart sounds, fast heartbeat, and monitor EKG looking for dysthymias. Assess vitals especially BP, BP should be kept low in heart failure patients to put less stress on the heart. Assess the patient for edema as a result of fluid retention. Listen for crackles in the lungs due to fluid built up. Watch I&O’s and weight the patient to assess for edema, ask about activity intolerance. Assess for changes in mental status, cool extremities, pale or cyanotic, fatigue, and JVD (Indications of poor perfusion) (Ignatavicius &Workman, p.756).
These have help development an intensive rehabilitation program for the patient. It will take an active involvement by the patient to assure optimum recovery.
Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored.
Staff nurses in many medical settings such as Skilled Nursing Facilities are at the forefront of patient care. Many patients in these particular settings are typically suffering from some type of cognitive impairment often related to dementia syndrome, behavioral disturbances or prior mental health conditions. Many mental health symptoms are managed by second generation antipsychotics. This class of medication placed the patients at risk for metabolic syndrome.
#4 Auscultated lung sounds, to monitor decreased airflow. RELATED TO LONG-TERM GOALS #5 Evaluate how much physical activity a patient can tolerate. Provide a calm, quiet environment for the patient. Limit patient’s activity/encourage bed or chair rest during acute phase.
Vital signs give valuable clues about the patient’s status (Brown & Edwards, 2012). Pritesh was in respiratory distress, reflected in his low oximetry readings of 93% on room air (RA) and increased respiratory rate (RR) of 26 breaths/min to compensate for inadequate oxygenation (Brown & Edwards, 2012). Insufficient ventilation is caused by inability to fully inflate the lung due to built-up intrathoracic pressure (Panté & American Academy of Orthopaedic Surgeons, 2010). In addition, anxiety and severe pain increase oxygen demand and impede the ability to expand the chest, according to Potter (2013). Anxiety is also an early sign of hypoxia due to hypo-perfusion of the brain (Potter, 2013).
Assess lungs and heart sounds and inspect for evidence of early heart failure, e.g. tachycardia, dyspnea. pulmonary congestion,
The patient I have chosen who has an issue with ventilation and perfusion is A.Z., a
The ability to carry out and document a full respiratory and cardiovascular assessment is an essential skill. The severity of illness can be initially evaluated by inspection, palpation, percussion, and auscultation. During analysis, specific locations of symptoms can be identified using landmarks such as the midaxiallary, midclavicular, and, the midsternal line. Indicate anterior or posterior thorax, and use the midaxillary line location when applicable (Bickley & Szilagyi, 2013).
An electrocardiogram (ECG) is one of the primary assessments concluded on patients who are believed to be suffering from cardiac complications. It involves a series of leads attached to the patient which measure the electrical activity of the heart and can be used to detect abnormalities in the heart function. The ECG is virtually always permanently abnormal after an acute myocardial infarction (Julian, Cowan & Mclenachan, 2005). Julies ECG showed an ST segment elevation which is the earliest indication that a myocardial infarction had in fact taken place. The Resuscitation Council (2006) recommends that clinical staff use a systematic approach when assessing and treating an acutely ill patient. Therefore the ABCDE framework would be used to assess Julie. This stands for airways, breathing, circulation, disability and elimination. On admission to A&E staff introduced themselves to Julie and asked her a series of questions about what had happened to which she responded. As she was able to communicate effectively this indicates that her airways are patent. Julie looked extremely pale and short of breath and frequently complained about a feeling of heaviness which radiated from her chest to her left arm. The nurses sat Julie in an upright in order to assess her breathing. The rate of respiration will vary with age and gender. For a healthy adult, respiratory rate of 12-18 breaths per minute is considered to be normal (Blows, 2001). High rates, and especially increasing rates, are markers of illness and a warning that the patient may suddenly deteriorate. Julie’s respiratory rates were recorded to be 21 breaths per minute and regular which can be described as tachypnoea. Julies chest wall appeared to expand equally and symmetrical on each side with each breath taken. Julies SP02 levels which are an estimation of oxygen
The patient is a 55-year-old man admitted to the hospital for dehydration secondary to vomiting. The physical examination of the patient revealed dry mucous membranes and vital signs as follows: Pulse 110, blood pressure 100/60, and respirations of 20.
Emory University Hospital is a teaching facility that embodies an “organizational culture that encourages critical thinking and acknowledges the inevitability of change” (Rubenfeld & Scheffer, 2015). By embracing a culture of change, Emory strives to fulfill its mission of “serving humanity by improving health.” This mission is being fostered, on my unit in particular, by the implementation of the evidence-based practice of an Accountable Care Unit (ACU). This transformational care model empowers nurses as leaders by giving them a voice and platform to advocate on their patient’s behalf. On my unit, these nurse leaders implement an ACU by offering and collecting information through their interaction with an interdisciplinary team, the patient,
The second intervention to improve gas exchange related to ineffective airway clearance is the use of a positive expiratory pressure device (PEP). PEP devices work by providing constant backwards pressure on the airways during expiration.
In order to promote patient learning, it is valuable to have a good teaching plan in mind. References Cleveland Clinic, 2014 -. Lifestyle is key to diabetes self-management. Retrieved from: http://my.clevelandclinic.org/disorders/diabetes. Kirk, Julienne., Stegner, Jane., 2010.