Question

Patient Profile: Rehabilitation Phase: B.V. is now 1 mo postinjury and is currently at a local inpatient SCI rehabilitation facility. He has since been extubated and uses a wheelchair to mobilize. He eats three meals a day with assistance and is on a strict bowel and bladder program. Subjective Data: Awake and alert but anxious Complaining of severe headache, blurred vision, and nausea Objective Data: Physical examination Flushed and diaphoretic above level of injury No bowel movement for 2 days BP 235/106mm Hg, pulse 32beats/min, respirations 30breaths/min and labored

Discussion Questions (Rehabilitation Phase)

1. Priority Decision: based on the assessment data provided, what are the priority nursing diagnoses?

2. Patient and family involvement in rehabilitation process is vital. What teaching will you provide about bowel movement?

3. Evidence Based Practice: B.V and his family are concerned about the potential risk of autonomic dysreflexia. What information would you provide the patient and Family?

Answer 1

1.The priority nursing diagnosis are

• Impaired gas exchange related to decreased mobility secondary to surgery, extubation ,anxiety
• Decreased cardiac output/function related to increased blood pressure as evidenced by vital signs, headache, blurred vision, nausea
• Impaired bowel pattern related to decreased peristalsis as evidenced by no bowel movement for 2 days
• Risk for fall related to blurred vision secondary to hypertension

2.The following teaching can be provided in regards to bowel movements are

• Encourage to mobilize the patient which can improve the peristalsis
• Increase the fiber intake ,plenty of fluids can be given
• Administer laxative as per order to relieve constipation

3.The following information can be given to the family

• Encourage the family members to administer medication as per order
• Monitor blood pressure
• Encourage the client to west loose garments
• Educate about the digital stimulation to improve bowel movements
• Bathroom training ,scheduling can be done to make it has a routine
• Health educate about the disease condition and its progress