Location: Rehabilitation unit 0800
Report from charge nurse:
Situation: Kim Johnson is a 26-year-old female police officer with paraplegia from a thoracic 8 (T8) spinal cord injury. She was transferred to us yesterday.
Background: The complete spinal cord injury was caused by a low-velocity gunshot wound to her back at the T8 level while she was responding to a robbery 8 days ago. The bullet penetrated the spinal column with no injury to visceral organs.
Assessment: Last bowel movement was yesterday at 1900, and the gunshot wound appears healed. Her neurological status is stable. She is awake and oriented. Bilateral upper extremity motor response is +4, and there is no movement or sensation to the lower extremities. She has been out of bed to a wheelchair. She is on a regular, high-fiber diet, and had breakfast at 0700. At 0400 she was catheterized for 300 mL of clear, yellow urine. The measured urine volume from the bladder scan 5 minutes ago was 321 mL.
Recommendation: She is due for assessment of vital signs and the 0800 intermittent urinary catheterization, which can be done after you have reviewed the chart. You should also begin the patient education on her bladder management program and the steps for a straight catheterization. The physical therapist is scheduled to see the patient at 1030.
2 subjective data, 2 objective data
One nursing diagnosis
2 long term goals, 2 short term goals
4 interventions with rationales
4 evaluations of goals, 4 evaluations of intervention
Impaired Physical Mobility related to paraplegia.
Long term goals:
improving lower body mobility;Spinal cord injury recovery(neuroplasticity of spinal cord).
Short term goals:
Proper urinary elimination;
Normal vital signs.
INTERVENTIONS WITH RATIONALE:
Stretching the legs can help lengthen spastic muscles and minimize pain caused by additional pressure on the joints.
2.Passive Range of Motion Exercises
Practicing passive range of motion exercises will help prevent joint stiffness, promote circulation, and stimulate the spinal cord.
Strengthening exercises are an essential part of physical therapy for paraplegia because they help maintain muscle mass.
Gait training not only focuses on developing coordination and strength in the legs, but also on building balance through the core.
EVALUATION OF GOALS:
Maintain a bladder management program.
Maintain a good physical mobility.
Maintain a normal pulse,blood pressure and respiration.
Spinal cord rewire and strengthen its neural pathways;sensation and motor activity.
EVALUATION OF INTERVENTIONS
Good muscle mass.
Good balance and coordination.
Maintain pressure in joints.
Maintain circulation and spinal cord stimulation.
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