Question

Case Study- Mobility Adaptive

You have been assigned to care for Mr. Rich Tilly, a 32-year-old admitted to your short-term rehabilitation unit after a lengthy hospitalization following a bike crash that occurred during a triathlon competition. He had sustained a closed head injury resulting in a 14-day coma but is now awake, alert, and oriented. He also had fractures to the right femur and tibia and right radius. The leg fracture sites were stabilized with external fixation devices providing skeletal traction. He has a fiberglass cast on his right arm extending from his hand to his elbow. He can bend the right elbow. He is permitted no weight-bearing on the right leg. Goals of his rehabilitation include reconditioning and independence in mobility and self-care activities.

1. Due to the prolonged recovery from his head injury as well as musculoskeletal compromise, Mr. Tilly is at risk for the hazards of immobility. Discuss the system changes you should be looking for during the admission assessment. Include both a subjective (how would the patient verbalize the problem) and the objective measurements (physical assessment data) of the potential system effects.

System Effects of Immobility	Objective Data	Subjective Data
Musculoskeletal	Observable abnormalities in the extremities X-rays Ask patient to perform ROM activities	Recurrent pains, Dull aches, stiff joints, Swelling, Fatigue
Respiratory	Shortness of breath Wheezing Persistent cough Chest X-Rays Auscultate lung sounds Dyspnea
Cardiovascular
Integumentary Gastrointestinal
Genitourinary	Lab tests - creatinine Imaging tests, blockage CT scan for imaging kidneys	Abdominal pains Frequent urination due to bladder muscle weakness.
Psychological

Mr. Tilly says to you during your morning assessment, “I just don’t know how I will ever recover from this—I can’t do anything for myself—I am so used to training every single day and now I can’t do anything I would call exercise. How can I get ready for all this rehab work?”

2. What type of exercise should be initiated with Mr. Tilly to regain muscle strength? Why?

3. Mr. Tilly wants to be able to help himself reposition in the bed telling you, “I am either stuck in one spot or sliding down in the bed. I want to be able to move myself instead of asking the staff to help me.” Keeping his injuries and treatment methods (external fixation and casting) in mind, what kind of positioning devices would be appropriate for him to use?

4. Discuss concerns with Mr. Tilly’s external fixator (skeletal traction). What are your priority assessments? How would you care for the site?

After completion of admission protocols the physician writes the following orders:

• OOB to chair for all meals, no weight-bearing to right leg

• May ambulate to bathroom with assistance, instruct in use of walker

4. . Mr. Tilly wants to get out of the bed as soon as possible. You sit him on the side of the bed but he complains of being “woozy and nauseated.” What is happening to him and how will you intervene?

5. How could you have assessed for the potential of this event occurring in this patient?

6. In consideration of the methods available to transfer patients out of bed, which method would be best to implement for Mr. Tilly at this time? Give a rationale for your decision.

7. Discuss the proper body mechanics that are imperative to safe patient care and transfers in any situation.

A week after admission Mr. Tilly is progressing slowly in his rehabilitation. He has verbalized frustration at his inability to ambulate freely. He states, “I just don’t know 264 Unit 4 | Supporting Physiological Functioning 2923_SE_Ch32_261-268 13/01/14 2:06 PM Page 264 if I am ever going to get better and some days don’t even feel like trying.” He has difficulty walking the required distances due to his musculoskeletal impairment and fatigue and has resorted to using a BSC instead of using the bathroom with assistance.

8. Formulate two nursing diagnoses, using a three-part format, that reflect the present issues being experienced by Mr. Tilly.

9. For each nursing diagnosis, identify the most appropriate outcomes for this patient. Develop an individualized goal for each that reflect the uniqueness of Mr. Tilly’s present situation.

10. Formulate three appropriate nursing interventions to facilitate the goals from above that are individualized to Mr. Tilly’s present health status.

11. At the sixth week of his recovery, the cast on his right arm is removed after diagnostic radiology shows that the fracture to the right radius has fully healed. The wrist and hand joints are very stiff and weak, and he is encouraged to move them as much as possible. Describe the aspects of range of motion of those joints that you should teach Mr. Tilly to do to facilitate a full return of function in that extremity.

Wrist:

Hand/Fingers:

12. Gaining strength in the arm has been a positive enforcer for his recovery. He asks you, “Why can’t I have a pair of crutches instead of that walker to help me get around?” Using an SBAR format, how would you address this with the physician?

13. Describe how you would teach Mr. Tilly to use crutches. What are the safety concerns you should address with him in the use of this modality?

Answer 1

System effects of immobility.
Subjective data. Objective

1) musculoskeletal- Fatigue , swelling , stiff

Joints , recurrent aches , dull pain. X-ray Of joints .
2) respiratory - subjective data - difficulty in breathing, tightness in the chest , pain on exertion .
objective data - chest X-ray APview , lung ascultate look for wheeze . Respiratory rate .
3) cardiovascular - subjective data -ortho pea, sweating, nausea , palpitations.

objective data - to assess patients blood pressure , pulse rate , assessment of fluid loss and gain . Look for cyanosis ,
4) gastrointestinal- subjective data - dysphasia, bowel function poor , loss of appetite , dyspepsia

objective data - abdominal examination all the 9 quadrants , usg ultrasound abdomen , ask for urinary frequency,

5) pschycological- subjective data - mood swings , agitation, carelessness, anger

objective data - assessment of cognitive function, evaluating concentration level , enquiring into interests and level of activity .

B) To gain muscle strength again the patient should do following excercise- 1) isometric excercise- it should be pain free

2) straight leg raises

3) hamstring curl

4) crossover arm stretch.

as there are so many parts I can't answer all .