NR 226 RUA Fundamentals Patient Care
Student Name
Chamberlain University
NR-226: Fundamentals – Patient Care
Prof. Name:
Date
Assessment
| Component | Description |
|---|---|
| Percussion | The patient’s documentation does not provide specific details regarding percussion. Percussion typically assesses sounds such as tympani (drum-like) over hollow organs and dullness (muffled) over solid organs, like the liver and spleen. |
| Auscultation | Bowel sounds are documented as normative, signifying normal frequency and intensity. Breath sounds are clear, although diminished at the lung bases, which suggests reduced air entry in those areas. |
| Neurological Exam | The patient is oriented to person, place, and time, indicating intact cognitive function. A gross evaluation of cranial nerves II-XII reveals intact function. Reflexes in the upper extremities are normal (graded 2+), while lower extremity reflexes are absent, which is expected in cases of paraplegia. The patient exhibits paralysis in the lower extremities, with no sensation below the T4 dermatome, consistent with spinal cord infarction. |
Pathophysiology
| Component | Description |
|---|---|
| Functional Changes | Due to the fractured extremity, the patient’s ability to move it is reduced as the bone structure and surrounding tissues are compromised. An inflammatory response increases pain and blood flow to the area, possibly causing redness and warmth unless obstructed by the fracture type. |
| Inability to Support the Body | The T4-T5 fracture hinders the body’s ability to bear weight, impairing walking ability. The nerve disruption affects motor signals, preventing necessary body movement. |
Reflection
| Component | Description |
|---|---|
| Communication | Active listening will be employed to address D.M.’s concerns and needs, fostering a stronger therapeutic relationship. Non-verbal communication strategies, including eye contact and culturally sensitive approaches, will be used to respect D.M.’s preferences. |
| Safety/Infection Control | Measures to prevent DVT, muscle atrophy, decreased healing, and pressure ulcers will be implemented. Infection control practices, such as diligent hand hygiene and catheter care, will be followed. Regular monitoring for signs of infection at the incision site will ensure optimal recovery. |
References
Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing, 46(12), 36-41. https://doi.org/10.1097/01.NURSE.0000504674.19099.1d
Santos, C., Almeida, M., & Lucena, A. (2016). The Nursing Diagnosis of risk for pressure ulcer: content validation. Revista Latino-Americana de Enfermagem, 24, e2693. https://doi.org/10.1590/1518-8345.0782.2693
NR 226 RUA Fundamentals Patient Care
Suarni, L., Nurjannah, I., & Apriyani, H. (2015). Nursing and collaborative diagnoses on perioperative with and without using six steps of diagnostic reasoning methods. International Journal of Research in Medical Sciences, 3(Suppl 1), S97-103.
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