CRITICAL THINKING SUMMARY

Student _Sydonie Stock_ Client Dx_ Blunt Head Trauma__ Age _52_ Allergies _NKA___

The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Motor Vehicle Accident: open L pelvic fx, R elbow fx, R rib 7-12 fx, liver lac

PATHOPHYSIOLOGY of diagnosed disease: (From text)
Motor vehicle accidents are the most common cause of blunt trauma (p. 593).
Blunt head trauma occurs when the head accelerates and then rapidly decelerates or collides with another object (p. 1921)



Smeltzer, S. C., Bare, B. G., Hinkle, J. L, & Cheever, K. H. (2010). Brunner & Suddarths textbook of medical-surgical nursing (12
th

ed.) (Vols. 1-2) (pp. 593, 1921). Philadelphia, PA: Lippincott Williams & Wilkins.

SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Symptoms of rib fracture are: severe pain, point tenderness, and muscle spasm over the area of the fracture that are aggravated by
coughing, deep breathing, and movement (p. 594)
A cerebral contusion is characterized by loss of consciousness associated with stupor and confusion (p. 1921)


CLIENTS SYMPTOMS of the diagnosed disease include:
Pain, confusion, difficulty breathing



NUTRITIONAL ASSESSMENT:
Height (actual or estimated) _67.32 in_______ Weight (actual or estimated) __158.84 lb____

Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5) _169.61 lb__

Does this client have characteristics of a well-nourished person? Yes _____ No __X____
Explain your answer.
He had good elasticity in his skin and his protein and albumin levels were within normal limits, but his mucus membranes were dry
and his body is requiring increased metabolic intake to heal.



PSYCHOSOCIAL STAGE OF DEVELOPMENT

What is the clients developmental stage?
Middle Adulthood. Generativity vs Stagnation is the conflict. The major event is Parenting.

Cramer, C., Flynn, B., & LaFave, A. (1997). Summary Chart. Erikson. Retrieved from http://web.cortland.edu/andersmd/erik/su

Has he/she met the necessary accomplishments? Yes _____ No __X___
Explain
No one has come to visit him since hes been admitted. The woman who was in the car with him during the accident identified him at
the scene, but no one has given a formal identification.
Another odd thing, not judging, but his toenails are painted pink.

How is this illness affecting the clients ability to meet these necessary accomplishments?
He is unable to communicate with the healthcare staff in order to give a health history or to request we contact family on his behalf.


STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress.
He is sedated, room lights are kept low, cluster activities, reorient frequently



NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnosis that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Impaired verbal communication related to presence of endotracheal tube (p. 253)

DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Cannot speak, disoriented to space (p. 253)

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Client will use alternative methods of communication effectively by day 3 (p. 254)

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1. Nurse will use therapeutic communication techniques: speak in a well-modulated voice, use simple communication, maintain
eye contact at the clients level, get the clients attention before speaking, and show concern for the client (p. 254)

2. Nurse will obtain communication equipment such as electronic devices, letter boards, picture boards, magic slates, and
intelligent keyboards (p. 254)

3. Nurse will use an individualized approach, establish an alternative method of communication such as writing or pointing to
letters, word phrases, picture cards or simple drawings of basic needs (p. 254)

#2 NURSING DIAGNOSIS (problem r/t)
Acute pain related to muscle spasms (p. 547)

DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Increased heart rate and blood pressure, grimacing (p. 547)

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Client will display a decrease in pain-related behaviors by day 2 (p. 547)

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1. Nurse will assess the client for pain presence routinely at frequent intervals (p. 548)

2. Nurse will consider the clients condition and search for possible causes of pain, observe for behaviors that may indicate pain
presence, evaluate physiological indicators, and conduct an analgesic trial (p. 548)

3. Nurse will administer appropriate, non-sedating, analgesics as ordered to reduce client pain (p. 548)


Ladwig, G. B. & Ackley, B. J. (2011). Mosbys guide to nursing diagnosis (3
rd
ed). Maryland Heights, MO: Mosby Elsevier

COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
Many things could happen to worsen his condition. He could get a DVT that travels to the lung from his ORIF pelvic surgery. A
broken rib could puncture the right lung causing atelectasis. Todays goal was to extubate; if this happens, he could fatigue trying to
breathe on his own.

How would you know this is happening?
From the PE and collapsed lung, there would be increased pain and difficulty breathing. The atelectasis could present with a
mediastinal shift. The fatigue would be apparent by bradypnea, decreased SaO2, and decrease LOC.

What will you do if this happens?
The true cause of the decline would be determined. For the PE, I would expect orders for clot busting medication and possibly a trip
to IR to remove the clot. The collapsed lung would need a chest tube and possibly surgery to repair the tear in the pleura. The fatigue
would be resolved by restarting the intubation and ventilation process.


EVALUATION:
Was the patient able to achieve the objectives identified on the first clinical day? yes no n/o
If no, list new objectives.


Did you choose the appropriate nursing diagnosis on the first clinical day? yes no
If no, list nursing diagnosis that would have been more appropriate.


Were the interventions appropriate? yes no n/o
If no, list more appropriate interventions.

PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

MEDS/IVS/TX/DIET
(Include dose, route,
frequency)
REASON PRESCRIBED
(Drug Classification
What is it treating?)
NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse reactions,
preparation & administration
concerns)
PATIENT DATA FROM
YOUR ASSESSMENT
(What data is important to know
before & after giving)
ceFAZolin 2G IVBP q8h
60mL/h
(Ancef, Kefzol)
Cephalosporin

Tx: open fx, surgical infection
risk
Diarrhea, mouth sores, rash,
numb/tingling, weakness, fever,
bleeding, oliguria, stomach pain
Skin assessment for rash/sores,
bleeding, temp, output, neuro-
assessment
chlorhexidine
4x daily
Broad spectrum antimicrobial

Tx: oral care
Severe irritation of skin,
burning/itching, redness,
blistering, peeling skin
Suction while providing oral
care
Bisacodyl 10mg
suppository PRN
constipation
Contact stimulant laxative

Tx: constipation
Dizziness, faintness, muscle
weakness, abdominal cramps,
burning sensation in rectum,
alkalosis, fluid and electrolyte
imbalance, hypokalemia
Before giving suppository,
determine if pt has adequate
fluid intake and diet, use for one
week only to prevent long term
adverse effects
fentaNYL 2500mcg IV
25mL/h
Opioid analgesic

Tx: pain
Asthenia, clouded sensorium,
confusion, euphoria, sedation,
somnolence, seizures,
arrhythmias, constipation, apnea,
hypoventilation
Drug-drug: watch for additive
affect with MAOIs, anesthesia,
CNS depressants, sedatives,
alcohol use
fentaNYL 25mcg IVP PRN
pain
Opioid analgesic

Tx: breakthrough pain
See above See above
Propofol 100mL IV
2.17mL/h
Titrate to RASS sedation
goal
Sedative/ hypnotic

Tx: sedation
Bradycardia, hypotension,
apnea, respiratory acidosis,
burning or stinging at injection
site
Use caution with
hemodynamically unstable pts,
drug-drug: additive affect with
opioid fentaNYL


Analysis of Diagnostic Tests

DIRECTIONS:

1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications)
and provide the patient values for each test. Explain why they are pertinent for this patient.

2. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased
or decreased in relation to your patient's medical condition.

Diagnostic/Lab Test Patient Values Analysis of Values

Calcium Lvl Total

7.0 L
His body is pulling calcium from the blood
back to the bones to heal the fractures

pH Art

7.46 H
Compensated respiratory acidosis

pO2 Art

118 H

Base Excess Art

2.3 H

Hgb

10.4 L
Recovering from open fx and surgery both
have blood loss factors

Hct

31.3 L Open fx and surgery