Question

Case Study, Chapter 10, Principles and Practices of Rehabilitation

1. Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient’s right side is paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medical-surgical unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not reposition her for hours. (Learning Objectives 2 and 4)

Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?

What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

2. You are assigned to care for David Ramsey, a 22-year-old male patient who sustained a back injury secondary to being thrown from a motorcycle. He did not damage the spinal cord, but the computed tomography revealed a compression fracture at L-2 (lumbar area). David complains of severe lower back pain with numbness and tingling in the lower extremities. You identify the following nursing diagnosis: Impaired Physical Mobility.

(Learning Objective 4)

What assessments are indicated based on this nursing diagnosis?

List other major nursing diagnoses based on David’s clinical presentation.

Answer 1

#1. CASE STUDY OF MRS. ADAMS: STROKE: PRESSURE ULCER/ DECUBITUS ULCER: are localized areas of cellular necrosis that develops when the external pressure is greater than the capillary pressure. PATHOPHYSIOLOGY: After a stroke , patients are at particular risk for pressure ulcers because of having numerous factors contributing to skin breakdown. They include a) abnormal sensation b) contracture c) malnutrition d) immobility e) muscle and soft tissue atrophy. NURSING INTERVENTIONS: STROKE: Nursing interventions of stroke rely at preventing secondary brain damage( to reduce the risk for intracranial pressure). The nurse should a) maintain the airway and b) providing the support by giving fluid and electrolytes and checking vital signs DECUBITUS ULCER: a) Turn the position of the patient every 2hours to stop ulcrs from forming. b) Place soft cushioning between bony prominences (ankles, wrist and other hard bone areas) where pressure ulcers can easily form.c) Keep the skin dry and moisture free to reduce the risk of developing pressure ulcers. d) The nurse should inspect the skin daily for areas of redness and warmth , to find out the signs of forming pressure ulcers.GLOBAL APHASIA: a) The nuse intervention for global aphasia include communication with the patient. While communicating the nurse should a) reduce the background noise and distractions to understand by the patient. b) use clear and simple language c) allow space for conversation (give the patient time to respond). #2. CASE STUDY OF DAVID RAMSEY: ASSESSMENT FOR IMPAIRED PHYSICAL MOBILITY: Impaired physical mobility is characterized by the following signs and symptoms such as a) inability to move or bend b) back pain c) muscle spasm d) anxiety OTHER MAJOR NURSING DIAGNOSIS: Other nursing diagnosis includes a) acute pain related to fracture, soft tissue injury and muscle spasm b) risk for periperal neurovascular dysfunction related to reduction in blood flow c) impare skin integrity related to increased susceptibility to falling that may cause physical harm d) risk for infection related to opening in the skin due to fracture.