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Posted: November 18th, 2022
Mr. Clark is a 26 Caucasian male
Mr. Clark is a 26 Caucasian male who was admitted to the rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst fracture after a MVA and the site was surgically stabilized. He is paralyzed in his lower extremities and has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure ulcer to his coccyx. Medical history includes substance abuse (alcohol) and obesity.
Mr. Clark is single and lives alone in a second story apartment. His parents live three states away and he has no relatives in the area. He is a seasonal construction worker, denies any religious affiliation and speaks English. Mr. Clark is a single man who lives alone on the second floor of an apartment building. His parents live in another state, and he has no family in the area. He works as a seasonal construction worker, is not religious, and speaks English.
Orders include:
Regular diet
Ensure high protein shake BID
Foley cath to dependent drainage
Dulcolax suppository every 3 days rectally
Baclofen 5mg PO QID
Midodrine 10 mg PO at 0800, 1300 and 1800
Sertraline 100mg PO daily
Hydrocodone 5/325 q 6 hours for moderate to severe pain
PT, OT TID, 5 days per week
Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily
Cervical collar when OOB
Transfer with sliding board per PT
Full resuscitation
Health Assessment, Health History, and Nursing Diagnoses
In this second submission of your Course Project, you will be completing a health history, physical assessment and client interview and determining their nursing diagnoses. This written assignment should include the following:
Describe the medical diagnoses of your assigned client (you need to research it). Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis is reason for being in the facility. If post-surgical, include surgery and reason for surgery. The secondary diagnoses include a history of pre-existing medical diagnoses). You need to include 4 secondary diagnoses. For each diagnosis, provide at least a 5-sentence explanation of the pathophysiology of the condition/problem. MAKE SURE YOU CITE YOUR SOURCES.
Write a detailed physical assessment and interview on your case study client. You will have to know what to expect in your client by using the information from #1 above and your case study. You will have to be creative.
5 Nursing diagnoses (only the NDx, you will complete the careplan for week 10). Make sure they are in the correct format. If you give me only the label you will not get any points for nursing diagnoses.
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