Case Study week 9 last Spinal cord T
Case Study Spinal Cord T.W.
NSG/340
Case Study
Plan for implementing these physician orders T.W. initial assessment and to stabilize him will be the priority following ABCs. The neurologic assessment every hour will provide T.W. general condition and information that can determine any changes. Oxygen will be given at 4 L per nasal cannula. The next will be stabilization of spine by immobilize the cervical spine to protect the spine and from causing more trauma. The preparation to administer fluid to maintain hemodynamic stability therefore, initiate two large bore IVs. An ECG monitor will be connected to record and detect heart conduction, disturbances or hyperkalemia. Also, a Foley catheter will be inserted that will assist T.W. with voiding and lastly, apply warm blanked as needed to prevent hypothermia and to maintain his temperature.
Other intervention by the nurse The nurse monitor level of consciousness, vital signs especially monitoring temperature because of the neurological deficit with the hypothalamus in the temperature regulation system has caused a dysfunction of the autonomic nervous system. Monitor pain level on a scale from zero means no pain to ten is the worst pain, the severity, if it radiates, sensation, if T.W. able to move leg, feeling or any movement. Continue to monitor for any changes, perform range of motion for all joints to prevent mobility loss and contractures. In addition, psychosocial assessment for T.W. well-being and include family members to provide comfort and support. Furthermore, continue IV fluid as order to prevent and decrease risk of neurologic shock. Cover with warm blanket as needed to prevent hypothermia.
Prehospital management The action that the nurse will take to ensure this goal is met is thorough assessment including collection of data or history of T.W. before the preceding injury happen, mechanism of injury, and what can he recall before the moment of injury. Also, enquiring information from the first
NSG/340
Case Study
Plan for implementing these physician orders T.W. initial assessment and to stabilize him will be the priority following ABCs. The neurologic assessment every hour will provide T.W. general condition and information that can determine any changes. Oxygen will be given at 4 L per nasal cannula. The next will be stabilization of spine by immobilize the cervical spine to protect the spine and from causing more trauma. The preparation to administer fluid to maintain hemodynamic stability therefore, initiate two large bore IVs. An ECG monitor will be connected to record and detect heart conduction, disturbances or hyperkalemia. Also, a Foley catheter will be inserted that will assist T.W. with voiding and lastly, apply warm blanked as needed to prevent hypothermia and to maintain his temperature.
Other intervention by the nurse The nurse monitor level of consciousness, vital signs especially monitoring temperature because of the neurological deficit with the hypothalamus in the temperature regulation system has caused a dysfunction of the autonomic nervous system. Monitor pain level on a scale from zero means no pain to ten is the worst pain, the severity, if it radiates, sensation, if T.W. able to move leg, feeling or any movement. Continue to monitor for any changes, perform range of motion for all joints to prevent mobility loss and contractures. In addition, psychosocial assessment for T.W. well-being and include family members to provide comfort and support. Furthermore, continue IV fluid as order to prevent and decrease risk of neurologic shock. Cover with warm blanket as needed to prevent hypothermia.
Prehospital management The action that the nurse will take to ensure this goal is met is thorough assessment including collection of data or history of T.W. before the preceding injury happen, mechanism of injury, and what can he recall before the moment of injury. Also, enquiring information from the first