SOLVED38

Spinal Cord Injury A long-term acute care (LTAC) nurse receives report for a client being transferred from the hospital. S A 36-year-old male with paraplegia secondary to motor bike accident; Admitted via ER 15 days ago, spinal cord injury with complete transaction at T3, multiple fractured ribs, right hemothorax, fractured right tibia, fibula, and ankle B PMH:     Allergies:
Family: Healthy male, no medical history prior to accident, immunizations up-to-date
Open reduction internal fixation of right lower leg and ankle
Right chest tube—removed 2 days ago
Tracheostomy—placed 6 days ago, Shiley 8 cuffless with inner cannula
Cervical spine cleared, activity as tolerated
NKDA
Parents (legal next of kin), Ex-wife, Two children ages 6 and 4 A Vitals: Pain: Neuro: Cardio: Resp: GI: GU: Skin: Temp 98.2° F (36.8° C), HR 83 beats/min, BP 118/54 mm Hg, RR 12 breaths/min, Sats 96% Rated 4/10, right leg and chest, oxycodone 10 mg per peg tube administered 45 min ago Alert and oriented; PERRLA; no sensation or movement below chest nipple line; hypoesthesia present in fingers and forearms; bilateral shoulder and gross arm movements against gravity only Sinus rhythm; capillary refill <3 sec; right upper arm PICC, dual lumen, heparin locked Mechanical ventilation—assist-control, rate 12, TV 750, FiO2 30%; lung fields clear throughout; weak cough; scant clear secretion via manual suctioning Bowel sounds present; peg tube with tube feeding and water boluses every 6 hr; last BM—yesterday; 24-hr input = 2400 mL Indwelling catheter; yellow urine without sediment; urinary bag emptied upon transporting client; 24-hr output = 2580 mL Warm and dry; pins present in right lower leg and ankle, no drainage R Rehabilitation consultations—physical therapy, respiratory therapy, psychological social worker, or counselor Case management for care coordination and long-term placement Two hours after admission to the LTAC facility, the client reports a severe throbbing headache. The nurse completes an assessment with the following findings. • Alert and oriented • Client reports his vision is blurry • HR 54 beats/min, BP 179/84 mm Hg, SaO2 91% • Pain reported 10/10—headache, throbbing • Sinus bradycardia • 2+ pulses, capillary refills <3 seconds • Chest rise symmetrically with respirations • Increased peak pressure per mechanical ventilator • Rhinorrhea, clear drainage • Diaphoresis • Flush face, neck and upper chest • Pin sites clean, no drainage 1 What information is most important?         2 What other information would help you establish the significance of the client's assessment data?       Further assessment data are obtained. The client's pupils are equal, round, and reactive to light. The client follows all commands, facial features are symmetrical, tongue is midline, and head and shoulder movements are at baseline. Lung fields are clear throughout and no kinks are identified in the mechanical ventilator tubing. Thin, pale pulmonary secretions are suctioned via the tracheostomy tube. The client's blood pressure is elevated in both arms with minimal differences in readings, and the client's apical pulse rate confirms bradycardia. Bilateral radial pulses and pedal pulses are palpable and equal. The client's abdomen is flat and not tender to palpitation. Bowel sounds are active in all quadrants. Fifty milliliters of yellow urine without sediment is present in the client's indwelling urinary bag and the tubing is wrapped underneath the client's left leg and buttocks. The nurse finds the client's bladder distended upon palpation. 3 What is the most likely explanation for this client's assessment data?      4 Which interventions are most important at this time?      5 How will the interventions identified be accomplished? SCIENCE HEALTH SCIENCE NURSING NURSE NURSE 401

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