Chapter 59 and 60 case studies mri confirmed

This preview shows page 4 - 5 out of 6 pages.

Chapter 59 and 60 – case studies MRI: Confirmed transection and revealed no clots or masses present Laboratory results: o White blood cells: 9500/µL o Hemoglobin: 16 g/dL o Hematocrit: 45% Discussion Questions 1. Based on the assessment data, what are the nursing priorities for M.P. at this time? Nursing priorities are to help decreased his low-grade fever this can indicate infection. It is also a possibility for him to have atelectasis since he has a T5 SPI , its very for common for him to develop it because it can cause paralysis of the abdominal muscle and also the intercostal muscles. We will also help him have a bowel movement because a lack of it can cause autonomic dysreflexia in SPI T6 and higher . AD most common cause is a distended rectum or bladder which is why it is a priority. 2. What actions do you need to take based on these priorities? For his low grade fever we will assess his lungs by auscultating them and hearing if there is any crackles, or rales and we will measure his oxygen saturation and do a chest x ray to see if there is an infection such as pneumonia. For his bowel movement we will ask him about his BM habits and assess his abdomen for bowel sounds and we will check his intake and output to make sure he is drinking enough liquids, because if he is not a lack in liquids can cause constipation. We can also assess his fiber intake, a lack of fiber can cause constipation .We can also do digital rectum exam to make sure nothing is obstructing the passage, we can also give him a enema to help pass his stools. For AD we will need to check if there is any other sign and symptoms that can indicate AD such as hypertension, throbbing headache, marked diaphoresis above the injury, bradycardia, piloerection from pilomotor spasm, flushing of skin above the injury, blurred vision or sports in visual field, nasal congestion, anxiety and nausea. Nasal congestion can also indicate a respiratory infection. 3. What is the rationale for the lower extremity elastic compression stockings and abdominal binder? The compression stockings and abdominal binder help to promote venous return . Pt is at risk for having DVT since lower extremities are not as they were before, and sitting in a wheelchair for long period of time also decreases blood flow and can be a risk for DVT. Since he has no feeling in legs DVT signs can be

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture