In your 5-day duty, you are required to document your care for 3 days (Day 2-5) based on 3 prioriti

In your 5-day duty, you are required to document your care for 3 days (Day 2-5) based on 3 prioritized problems using Focus Charting (FDAR). Be sure to indicate your patient’s vital signs using your own clinical judgment. CASE SCENARIO: YOU RECEIVED PATIENT MR. R. ESPINUEVA, 32-YEAR-OLD MALE, 5’7 IN HEIGHT AND WEIGHTS 85KG, SINGLE FROM CITY OF SAN FERNANDO, LA UNION, HE IS UNCONCIOUS AND NOT RESPONSIVE TO ANY STIMULI. HE HAS BEEN ADMITTED IN THE MEDICAL-ICU FOR ALMOST 1 WEEK AFTER POST- OPERATIVE CRANIECTOMY DUE TO SEVERE HEAD TRAUMA WITH INTRACRANIAL BLEEDING. HE ALSO SUFFERED A COMPLETE FRACTURE ON THE THORACIC SPINE LEAVING THE T4 AND T5 COMPLETELY SEPARATED. PATIENT IS STILL SCHEDULED FOR SPINAL SURGERY. HISTORY: PATIENT WAS HIT BY A SPEEDING CAR WHILE CROSSING IN A HI-WAY. ACCORDING TO SOME WITNESSES, PATIENT FLEW 25 METERS AWAY FROM WHERE HE WAS HIT AND HIS BODY HIT THE CONCRETE BARRIER. UPON ADMISSION TO MED-ICU, HIS VITAL SIGNS ARE THE FOLLOWING: BP: 90/60, PR: 59, RR: 15, O2SAT: 97% VIA ENDOTRACHIAL TUBE AND CONNECTED TO A MECHANICAL VENTILATOR. GCS: 3 LABORATORY RESULT: CBC: HGB: 100, HCT: 46, BLOOD TYPE: AB+, HGT: 64mg/dL, IMAGING STUDIES: (CTSCAN HEAD): TRAUMATIC SUBARACHNOID HEMORRHAGE;Midline traumatic SAH in the inter-hemispheric fissure or perimesencephalic cisterns may be a marker of diffuse axonal injury. SAH in the interpeduncular cisterns may indicate brainstem injury.X-RAY: APL- CERVICO-LUMBAR RESULT: COMPLETE FRACTURE T4-T5. ADMITTING DIAGNOSIS: SEVERE HEAD TRAUMA T/C SPINAL CORD INJURY COMPLETE FRACTURE THORACIC AREA SECONDARY TO SEVERE INTRACRANIAL BLEEDING. PHYSICAL EXAMINATION: SKIN IS MOIST AND WARM TO TOUCH, NO CYANOSIS AND EDEMA, UNCONSCIOUS, EYE PUPIL BOTH CONSTRICTED NO PUPILLARY REACTION TO LIGHT ACCOMMODATION. LUNGS WITH EQUAL AIR ENTRY ON BOTH SIDES NO ABNORMAL BREATHE SOUNDS NOTED. NO JUGULAR VEIN DISTENTION, NORMAL S1, S2 HEARD. PERIPHERAL PULSES FELT BILATERALLY. ABDOMEN SOFT, BOWEL SOUNDS NORMAL. GENITO URINARY TRACT NORMAL, ON IFC CONNECTED TO URINE BAG , YELLOWISH DISCHARGE NOTED, ON ENDOTRACHIAL TUBE CONNECTED TO MECHANICAL VENTILATOR, WITH INTACT NGT, WITH PATENT JP DRAIN IN THE HEAD, WITH INTRAVENTRICULAR CATHETER ATTACHED IN THE LATERAL VENTRICLE OF THE HEAD. MEDICATION: MANNITOL 20% IV (FD), 1.25 G/KG IV INFUSED OVER 30-60 MINUTES; MAY REPEAT Q6-8HR, DOBUTAMINE HCL 250MG/20ML (12.5MG/ML) 5mcg/KG/MIN, INCORPORATE TO 100 CC D5W VIA SOLUSET, PIPTAZ 2G Q6 INCORPORATE WITH 80 CC PNSS VIA SOLUSET TO MAKE IT 100CC, PARACETAMOL 300MG/2 ML IV PRN, GABAPENTIN 300 MG TAB PO Q8HR, NIMODIPINE 60MG Q4 PO  IV FLUIDS: 1 L 5% NaCl x 8 hrs, 500 CC D5W AS SIDE DRIP INCORPORATED TO SOLUSET. MANNITOL 20 % Q6.DIET: LSLF DIET OSTERIZEDCBG: BEFORE MEAL AND RECORD.VS/I&ODAY 1DAY 2DAY 3BP90/6080/60110/90PR6270120RR202020TEMP38.936.738.3O2 SAT989998FLUID INTAKE650 ML730ML800 MLFLUID OUTPUT500ML600ML740 ML FORMAT:DATE/TIMEFOCUSD – ATAA – ACTIONR – RESPONSE   D: A: R:  Health Science Science Nursing NURSING 409 Share QuestionEmailCopy link Comments (0)

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