Reference no: EM134005590

Question

Situation - You are working in the ED when you received a call that paramedics are on the way with a 24-year-old male patient that had been in a rollover auto crash. It is your turn for admission. His name is Mathew Smythe. EMS has just arrived as you finished with the call. Background - Mathew was out with his buddies' joy riding when a car pulled out in front of them causing them to swerve and in the process the car flipped over. Mathew was not wearing a seat belt and was tossed around in the car. Assessment - Mathew is strapped to a backboard and has a c-collar on. You are unable to get any kind of response when you call his name. When you do a sternal rub, he moans and tries to move all of his extremities. His eyes are PERRLA. His skin is pale brown. When you listen to his lungs, they are clear bilaterally. He has equal lung expansion bilaterally. His heart tones are normal S1 and S2. His abdomen is rounded and soft with hypoactive bowel sounds. His bladder is palpable and feels full. Peripheral pulses are all 2+ bilaterally. Vital signs are as follows: HR - 110, RR - 20, BP - 140/80 (100), T - 36.2° C (97.1°F). Other than a few minor abrasions on his hands, his skin is intact. He has an 18-Gauge IV catheter inserted in his left antecubital area with 0.9% Normal Saline infusing at keep open.

Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?

Recommendation(s) -

1. What are the risk factors for this patient, and do they contribute to the current primary problem?

2. What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.)? What signs and symptoms are commonly seen with this diagnosis?

3. What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) What lab values may be abnormal?

4. What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)

5. What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.) Which intervention would be best for this patient?

6. What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) What changes to the patient's condition would I expect to see happen or have happened?

7. What is the worst possible/most likely complication(s) to anticipate based on the primary problem (to prevent death)?

8. What nursing assessments/interventions will identify this complication EARLY or prevent it from happening if it develops?