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Prof. Name
Date
Assessment
| Component | Description |
|---|---|
| Percussion | The patient documentation lacks specific information regarding percussion. Typically, percussion evaluates sounds such as tympani (drum-like) over hollow organs and dullness (muffled) over solid organs like the liver and spleen. |
| Auscultation | Bowel sounds are described as normative, indicating normal frequency and intensity. Breath sounds are clear, with diminished sounds at the lung bases, suggesting reduced air entry in those areas. |
| Neurological Exam | The patient is oriented to person, place, and time, showing intact cognitive function. A gross assessment of cranial nerves II-XII is intact. Upper extremity reflexes are normal (graded 2+), but lower extremity reflexes are absent, expected in paraplegic cases. Paralysis in lower extremities with no sensation below the T4 dermatome, consistent with spinal cord infarction. |
Pathophysiology
| Component | Description |
|---|---|
| Functional Changes | Due to the fractured extremity, the patient has a reduced ability to move it, as bone structure and surrounding tissues are compromised. The inflammatory response increases pain and blood flow to the area, possibly causing redness and warmth unless obstructed by fracture type. |
| Inability to Support the Body | The T4-T5 fracture prevents the body from bearing weight, impairing walking ability. Nerve disruption affects motor signals, preventing necessary body movement. |
Reflection
| Component | Description |
|---|---|
| Communication | Employing active listening to address D.M.’s concerns and needs, strengthening therapeutic relationships. Non-verbal strategies like eye contact and culturally sensitive communication will be used to respect D.M.’s preferences. |
| Safety/Infection Control | Measures for DVT, muscle atrophy, decreased healing, and pressure ulcer prevention will be implemented, along with infection control practices, such as diligent hand hygiene and catheter care. Regular monitoring for signs of infection at the incision site will support optimal recovery. |
References
Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing, 46(12), 36-41. https://doi.org/10.1097/01.NURSE.0000504674.19099.1d
+1 (206) 350-4565
support@nursingstudyhub.com