Question

M.P., a 19-year-old African American male, has a spinal cord injury following a gunshot wound 2 weeks ago. The gunshot injury occurred during a hunting accident when his best friend’s gun accidentally discharged. His injury is at the T5 level. The goal is to prepare him for transfer to a rehabilitation unit in the next few days.

Subjective Data

• Has just completed his first year of college as an engineering student
• States he is depressed and “he cannot get used to the idea of not walking again”

Objective Data

Physical Examination

• Supine blood pressure 120/68, sitting blood pressure 114/62, pulse 68, temperature 99.8° F, respirations 16
• Slight edema bilateral lower extremities – ace wraps wrapped around lower extremities
• Abdominal binder in place
• Urinary catheter intact and draining dark yellow urine
• Last bowel movement 2 days ago; it was hard, small and brown
• Full head, neck, shoulder and upper extremity movement with normal muscle strength and sensation
• Complete paralysis of lower body and legs with no sensation present
• Full passive range of motion without crepitation in the bilateral lower extremities

Diagnostic Studies

• Spinal series x-rays: Complete transsection at T5
• MRI: Confirmed transection and revealed no clots or masses present

• Laboratory results:
  • White blood cells: 9500/µL
  • Hemoglobin: 16 g/dL
  • Hematocrit: 45%

Case Study Progress

M.P. did not have any signs of autonomic dysreflexia. He had a large bowel movement after receiving a PRN suppository. Antibiotic therapy was initiated after results of a urinalysis with culture and sensitivity indicated a urinary tract infection. After 3 days of medication and fluid therapy, he is being transferred

1.Give 3 nursing dx to match the patient's condition with 3 intervention and goal outcomes.

2.Give a SBAR to the oncoming nurse in change of shift report.

Answer 1

nursing dx

1. Impaired Urinary Elimination
2. Infection
3. Acute Pain

Impaired Urinary Elimination related to Frequent urination, urgency, and hesitancy.

goal outcomes :

* The client will have a normal pattern of urine disposal, as evidenced by the absence of signs of urinary tract disorders (urgency, oliguria, dysuria).

* The client will demonstrate behavioral techniques to prevent urinary tract infections.

Interventions :

* Assess the patient’s pattern of elimination

* Encourage increased fluid intake

* Encourage the client to void every 2-3 hours.

Infection related to Improper toileting ,Indwelling catheter, Instrumentation or catheterization, Urinary retention

goal outcomes :

The client will be free from UTIs as evidenced by the absence of fever, chills, groin pain and suprapubic tenderness; Clear urine without a foul odor and a normal number of white blood cells.

Interventions :

* Assess for signs and symptoms of urinary tract infection.

* monitor WBC count.,Urinalysis., Bacteria in the urine., Urine culture and sensitivity

* Encouraged the client to void often every 2 to 3 hours a day and completely empty the bladder.

* Encouraged increased oral fluid intake

Acute Pain related to Inflammation and infection of the urethra, bladder, and other urinary tract structures.

goal outcome :

* The customer will use both medicinal and non-pharmacological pain relief strategies.

* Customer will report satisfactory pain control below level 3 to 4 on a scale of 0 to 10.

Interventions :

* Assess client’s description of pain such as quality, nature and severity of pain.

* Encouraged the use of a sitz bath.

* Apply a heating pad to the suprapubic area or lower back.

* Encouraged the use of analgesic