Bundy
C.L. Macy is a 34 year old African American male with a mother and an aunt, admitted to Cardinal Hill the weekend of September 8, 2007 for PT, OT, personal and family teaching he is in the spinal cord program. He received T2-T3 Spinal Cord Injury secondary to a gun shot wound when he was hit in the neck on 8/24/07, leaving him with paraplegia and a left scapula fx. The primary goal of CHRHs spinal cord program is to familiarize new injuries to living with a spinal cord injury, teaching family ADLs, so he can return home with assistance. VS: B/P: 118/76, P: 76, T: 97.9, RR: 14bpm, Sat: 99%, Blood Sugar: 115 GENERAL: (Height & weight unknown) overweight man reclined in his electric wheelchair sleeping in the therapy gym. Poor hygiene with odor radiating from him, long dirty nails, ashy skin; patient complaining of extreme pain today. (NORMAL FINDINGS: patient needs to have some dietary counseling, be bathed, with hair washed every few days, nails cleaned and cut and lotion applied to skin, pain should be monitored better). INTEGUMENT: Skin is free of breakdown. Elastic turgor. Dark pigments, dry, soft, and warm to touch (abdominal area covered in what seemed to be a very large ace bandage). (NORMAL FINDINGS). HEENT: Head normocephalic, symmetrical, proportional to rest of body. Hair course, dark, unevenly distributed in dreadlocks. Corneas clear, irises dark brown, conjunctivae clear, pink, with no discharge, sclera white with a tent of yellow. Tragus intact, no lesions present and auricle nontender. External auditory ear canal dark, intact, with no lesions or serulin present. Acoustic nerve intact. Nose same color as body, smooth, no nodules or
Macy Bundy
masses present. Septum intact and on the midline with turbinate's present and symmetrical. No change in smell. Lips symmetrical, smooth, dark & moist, with out lesions. Multiple teeth replaced by false gold teeth. Oral mucosa pink and moist with hard and soft palates. (While looking in the mouth, tonsils were not able to be seen). No change in taste. (NORMAL FINDINGS: Hair should be evenly distributed, all 32 teeth present with a slight overbite). NEURO: Lethargic and Obtunded, but oriented x 3, PERRLA @ 2mm, some sensation below T2-T3. Stereognosis intact and functioning not able to open hands for Graphesthesia. Cognitively, unable to focus long enough before pain would re-occur, unable to recall any recent events. (NORMAL FINDINGS: patient should be A & O x 3, have sensation across the body, open hand with eyes closed tell nurse what number she is writing in hand, listen to nurse and respond with full thoughts, correctly answer questions about current activities; recall significant past events). RESP: Rib slope less than 90 downward, AP/lateral 1:2, sternum level with ribs. Chest symmetrical and equal with 1"expansion. No pain or tenderness with palpation of intercostals spaces. Lungs clear on inspiration and expiration along anterior and lateral sides. Breaths 14/minute even and labored. (NORMAL FINDINGS: expansion of chest should be 3", with breaths being regular, even and unlabored). CV: Location of small apical pulse at mid-clavicular line 5th intercostals space (PMI), radial pulse weak, equal, bilateral, rate 76 bpm, regular rhythm, capillary refill < 3 seconds, S1 and S2 audible. Carotid pulses irregular, weak, and non-elastic. (NORMAL
Macy Bundy
FINDINGS: peripheral pulses should be strong as well as carotid pulses should have been regular, strong and elastic). (Pedial pulses and JVD not performed). GI/GU: Abdomen round, soft, nondistended, nonteder with light and soft palpation. Bowel sounds active in all 4 quadrents with no signs of bruits. No signs of rebound tenderness or guarding. Last BM 9/12/2007 pm. Cath. q4h on bowel Eating program. 0%25% of diet, drinking 0%-25% liquid. (Urine and genitalia never seen, no palpation of liver or spleen). (NORMAL FINDINGS) MUSCULOSKELATAL: Non-ambulatory, requires wheelchair for mobility, limited ROM only with assistance, pain level 8 (0-10 scale) in shoulders and back, weakness and tenderness with shrugging of shoulders and pushing arms against slight pressure. UES equal muscle size, LUE 2/5, RUE 3/5, hand strength bilaterally 3/5. All LES 0/5. In transfers patient requires total assistance. Full sensation in UES, limited sensation in LES, Proprioception negative. Assistance required for all ADLs. (NORMAL FINDINGS: Stance: weight evenly distributed, able to stand on right/left heels, toes, Erect posture. Gait smooth equal with toes pointing straight ahead. Full ROM UES and LES. Able to shrug shoulders against resistance with no tenderness. UES and LES bilaterally should be equal, with 4-5/5 muscle strength. Transfers should be self directed. Should have full sensation bilaterally in UES and LES. Positive proprioception. No assistance for ADLs). PSYCHOSOCIAL: No coping pattern developed. Does not have much visitation. Mildly cooperative. (NORMAL FINDINGS: Patient needs to develop a coping plan as well as a plan for his future. Family does not come and visit often because they live far away; however, patient would have a further rehabilitation and family may have a better chance
Macy Bundy
at taking him home if they did come a few times a week. Would have liked more cooperation and a less sedative patient.)
Teaching Plan C.L. had acute pain while I was at CHRH. A teaching need may be relaxation techniques such as slow, rhythmic breathing or deep breathing. This may help him when the hospital starts to decrease his opioid intake or when he is discharged. Reflection Yesterday I really think God was telling you (Jessica) that I needed to be with C.L. My feelings were ironic when I walked in to the therapy gym and I asked where C.L. was. I had expected a man of Latino or Hispanic descent and when the therapist pointed to a large African American I was bewildered. Between you and me, my first thought was what the...? Not that I am racist, but I have never been exposed to many African Americans and because of that my anxiety that was already in place, increased. Last year in 860 we were told and told not to discriminate against or judge people based on perceptions we had, and when I was in the class, I though if I heard that one more time I was going to kill someone! But based on my experience yesterday, I know exactly why they were trying to tell us that. I went in basically petrified, and when I came out I had learned that even though C.L. was black, he still need the care that I would expect for me or any of my family.
Macy Bundy
Yesterday was also eye opening because of meds. I knew we were going to do a "dry run" of medication giving, but I really didn't think about what that entailed. In lab we had been told do three checks, do three checks, do three checks, but when I got in the moment I was blank and had no idea of what to do or what to tell you. Thank goodness for the dry run! A strategy to improve after this week would definitely be writing down as much as possible. I took for granted doing assessments on normal adults all last semester. This semester though it's all different. I learned if I couldn't do weight, to look it up in a chart, because when it comes time to do your assignment for the week and you don't have it, there's nothing you can do. Next week I will try to meet my client and then go to his bedside chart and his doctor's chart and write down everything. Not only will this help me with my assignments, it will also help give me a baseline for further evaluation.