Reference no: EM133442622
Activity Case Study
C.R. is a 42-year-old white male who fell from a 60-foot scaffold while working on the construction of a new building. He is admitted to the emergency department (ED) by ambulance and is strapped to a rigid backboard with cervical immobilization. At the site of the accident, J.D.'s co-workers immobilized his body until the ambulance arrived. His supervisor called his wife.
C.R.'s wife arrives at the emergency room at the same time the ambulance arrives. She is very agitated and crying. He sees her as he is wheeled into the ED and reassures her that he is okay and tells her he fell at work. You take her to a waiting room, explaining that she can see her husband as soon as he is stabilized.
Initial physical findings include a flaccid paralysis and loss of sensation of the lower extremities and trunk. He has sensation and movement of the arms and hands with decreased grasp strength. His extremities are warm and dry. Vital signs are blood pressure (BP) 88/50, pulse 40 beats/minute, respirations 26 breaths/minute and shallow, and temperature 97° F (36.1° C). His clothing is torn in several places, revealing a large abrasion on his right shoulder, a bruised right upper arm, and a deeply abraded right upper leg. He complains of burning pain in his right upper arm and shoulder. He had bowel and bladder incontinence at the site of the accident but does not seem aware of it. He has a peripheral IV of normal saline at 75 mL/hr started by the paramedics.
What nursing activities would be a priority on C.R's arrival in the ICU? What physiologic problems are causing C.R. to have hypotension and bradycardia?
What would be the first line of treatment for C.R's hypotension and bradycardia? What signs and symptoms would indicate respiratory distress and what physiologic problem would cause respiratory distress in C.R.'s injury state? What can you do to decrease C.R.'s anxiety?
Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems?
Delegation Decision: Identify activities that can be delegated to unlicensed assistive personnel (UAP).