Question

Eric Smith is a 17 year old male who was involved in a fight with another teenager. During the fight, the alleged teenager picked up Eric and threw him to the ground. Eric landed on his neck, attempted to get up, but was unable to move. Eric stated that he was unable to move and witnesses called 911. The paramedics responded immediately, applied a cervical collar, placed him on a transfer board, and transported him to the Harper Medical Center emergency department.

Subjective Data:

·       “I can’t move my legs”.

·       “I landed on my neck”.

Objective data:

              Physical Examination

·       Cardiovascular: B/P - 80/60        AP – 42/regular               RR – 24/min O2 sat – 95% Carotid pulse felt but weak radial and femoral pulse palpated - 1+/1+

·       Temperature:    94.2

·       No anal sphincter tone present.

·       Ecchymosis noted on right upper arm and scapular area

·       Abrasions noted on face, right arm and back

·       No movement, sensation or pain noted in right or left leg

·       No movement, sensation or response to painful stimuli bilaterally in upper extremities.

Diagnostic Studies:

              CT scan reveals fracture in C5

Laboratory values:

              All labs within normal limits

Type and crossmatch:    B negative          Antibody screen – negative

1.           Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is ______________________________________________. What should the triage nurse do next?

2.           What is the data obtained from the primary assessment?

3.           What is the data that is obtained from the secondary assessment?

4.           What is the diagnosis that the nurse suspects and why does it occur? Interpret and explain all the data presented and its significance.

5.           What are some other causes of this diagnosis and what is your role in preventing it in other patients?

6.           What are the initial nursing responsibilities?

7.           What nursing assessments are essential and at what frequency should they be performed?

8.           List and prioritize three nursing diagnoses for this patient.

9.           What are some other collaborative problems that may occur?

10.         Document your findings on the flow sheet and also document your findings using narrative format.

Answer 1

1) upon the arrival to the emergency room, the triage nurse assesses the situation and deems that this is cerivcal trauma ,ient then the traige nurse should safely remove the cerrvical collar perform patient assessment and if patient is having any emergency nurse should attend and can also give immediate medical treatment and check vitals and nurse should follow till all the radilogical and other tests are conducted, 2) Data obtained from primary assessment:+-after assessing the patient primary is that the patient is unable to move and fell on his neck and check for life threating injuries, 3)Data obtaained from the secondary assessment from secondary assessment patient vitals and any injuries on the body is checked :, and other system of the patient is checked for they are normal or abnormal etc. 4) the nurse suspects of cervical trauma because when patient arrived to the emergency department with cervical collar and both the legs are immobile and no sensation, feelinfg on teh neck indcaites that the patient is injured on the neck and no anal sphincter tone present means that the nerves of the lower extermities is injured and no movement and pain sensation in the lower extremities and upper extremities show that the nerves that supply them are damaged etc. 5) they are 2 types of causes to the c5 injury they are traumatic spinal injury it may be due to sudden traumatic blow to the spine and dislocates , sruches, compression it may be due gun shot or knife wound that penerates and cut the spinal cord and nontraumatic injury due to arthritis, cancer, inflammation, and infections or disk degeneration of the spine etc. by educating the students and children and adults about the results of the trauma associated with the c5 injury, and always aviod lifethreatening incidents , wear seat belts, and safe driving and maintaing the home cleanliness and always follow playground safety and pool safety etc, 6) Initial nursing responsibilities:the initial nursing reponsibilities are assessing and planning nursing care requirement and providing monitoring and adminstrating medication and intravenous infusions writing records of the patient and taking patient samples , vitals , on right time. 7)nursing assessment : it involves initial assessment and reffering the patient to the concerned doctors and rehabilitation services, and immobilization of the injury, imaging and neurological assessment and checking of vital signs etc. it should be done according the emergency of the frcture of the patient. 8) 3 nursing diagnosis are ineffective breathing pattern, risk for injury and distrubed sensory perceptions, and risk for disuse syndrome .