CRITICAL THINKING SUMMARY

Student ____Lindsey Zolynsky_____Client Dx__trauma hit by car on bicycle Age _52___Allergies _NKA
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Scattered subarachnoid hemorrhages and multiple traumatic fractures.
PATHOPHYSIOLOGY of diagnosed disease: (From text) subarachnoid hemorrhage (SAH) is the direct hemorrhage of arterial blood
into the subarachnoid space. Immediately after bleeding begins, intracranial pressure (ICP) rises, resulting in a fall in cerebral
perfusion pressure. The expanding hematoma acts as a space-occupying lesion, as it compresses or displaces brain tissue.
Blood in the sub-arachnoid space may interfere with blood flow and reabsorption leading to hydrocephalus. Vasospasm is a
common side effect and can lead to further neurological deterioration, cerebral ischemia, and cerebral infarction.
Traumatic fractures of C5 and C6, right leg, and multiple facial. Fractures occur when the bone breaks and are classified as closed (no
skin wound), open/compound (bone protrudes through the skin or there is a break in the skin), complicated (broken bone injured an
organ), comminuted (bone is splintered into pieces), impacted (broken bone is wedged into the interior of the opposing end),
incomplete (line of fracture does not transverse the bone), and greenstick (partially bent and partially broken).

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SYMPTOMS typically seen with this diagnosis include (as identified in your text): SAH: severe headache, weakness, confusion,
inability to protect airway, loss of consciousness. Fracture: loss of movement, pain with acute tenderness over site, swelling and
bruising, deformity, and possible shortening.

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CLIENTS SYMPTOMS of the diagnosed disease include: inability to move left arm and partial movement of left leg, altered level
of consciousness, combative, swelling of face and abnormality of right leg.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated) __62__ Weight (actual or estimated) _____82.8kg/108.8 lb__
Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5) _____195 lb______
Does this client have characteristics of a well-nourished person? Yes _____ No __x__
Explain your answer.
The patient is very thin with a long history of alcohol abuse. Patient is 52 years old but looks much older. His ribs are protruding and
his legs are very bony.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the clients developmental stage? Generativity vs. Stagnation
Has he/she met the necessary accomplishments? Yes _____ No _x____
Explain
Although the patient has children, they have very little interest in his well-being. No one comes to see him at the hospital. His son was
extremely hard to reach to obtain consent for procedure, and when he was on the phone he seemed to care, but was overall
disinterested in the plan of care. The patient has a history of alcohol abuse.
How is this illness affecting the clients ability to meet these necessary accomplishments? He is unable to nurture relationships with
family due to his hospitalization. He is unable to have involvement in the world because he is bed bound and intubated.

STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress.
My assumption is the client copes by drinking. I was unable to speak with the patient or his family members because he was intubated
and his family did not visit.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnosis that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Risk for ineffective cerebral tissue perfusion r/t head trauma
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Recent trauma resulting in scattered SAHs and flaccid left arm
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Maintain perfusion so patients condition does not worsen
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. maintain euvolemia (having the proper amount of hydration)
2. monitor patient by perform Q4 neuro exams
3. maintain head of bed at 30-40 degrees
#2 NURSING DIAGNOSIS (problem r/t)
Ineffective airway clearance r/t intubation
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Adventitious breath sounds (crackles, wheezes), diminished breath sounds, and excessive sputum
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The patient will be extubated
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Turn patient every 2 hours and suction after turn
2. Auscultate breath sounds every 1-4 hours and monitor respiratory patterns
3. document results of suctioning, client tolerance, and secretion characteristics such as color, odor, and volume
COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
The most likely reason would be a lack of turning and suctioning
How would you know this is happening? His breathing would become labored and his lung sounds would worsen
What will you do if this happens? Continue care as planned and consult respiratory to evaluate patient and treatment plan

EVALUATION:
Was the patient able to achieve the objectives identified on the first clinical day? yes no x n/o
If no, list new objectives. The plan was to extubate the patient and place a trach but consent could not be obtained. Extubate patient
the following day and place a trach.
Did you choose the appropriate nursing diagnosis on the first clinical day? yes x
If no, list nursing diagnosis that would have been more appropriate.
Were the interventions appropriate? yes x no n/o
If no, list more appropriate interventions.

no

PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

MEDS/IVS/TX/DIET
(Include dose, route,
frequency)

REASON PRESCRIBED
(Drug Classification
What is it treating?)

NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse reactions,
preparation & administration
concerns)

Meropenem
2Gm=40mL, IVPB, q8hr
140mL/hr 60min

Anti-infective
Treatment of meningitis until
possible bacterial meningitis
ruled out
Anti-infective
Treatment of meningitis until
possible bacterial meningitis
ruled out

CNS: seizures Resp: Apnea GI:

Pseudomembranous colitis

Famotidine
20mg=I tab, PO/feeding
tube, bid

Anti-ulcer agent/histamine h2
antagonists
Lower gastric acid and
decrease opportunity for ulcer
formation during
hospitalization

CNS: HA, dizziness CV:

dysrhythmias HEMA:
thrombocytopenia, aplastic
anemia

Heparin
5, 000units=1mL, subQ,
q8hr

Antithrombotic/anticoagulant
Prophylactic treatment to
decrease chance of blood
formation during
hospitalization
Topical disinfectant
Reduce risk of acquiring
ventilator acquired pneumonia

CNS: fever, chills, headache

GU: hematuria HEMA:
Hemorrhage, thrombocytopenia,
anemia INTEG: rash, dermatitis
SYST: anaphylaxis
Mouth or throat irritation, dry
mouth, mouth or skin rash,
itching/swelling

Aspirin
325mg= 1tab, PO, daily

salicylate
Prophylactic treatment to
decrease chance of blood
formation during
hospitalization

Fentanyl
2,5000mcg (50mcg/hr)

Opioid analgesic
Used to treat pain and mildly
sedate

CNS: stimulation, drowsiness,

seizures, coma
CV: rapid pulse, pulmonary
Edema EENT: tinnitus
GI: GI bleeding, hepatitis
HEMA: thrombocytopenia,
agranulocytosis, leukopenia,
neutropenia, hemolytic anemia
SYST: anaphylaxis, laryngeal
edema
CNS: dizziness; sedation
CV: bradycardia, arrest
GI: N&V GU: urinary retention
RESP: respiratory depression,
arrest, laryngospasm

Vancomycin
1Gm=200mL, IVPB, q8hr
120mL, 100min

Chlorhexidine topical
1app=15mL, qid

CV: cardiac arrest, hypotension

GI: N/pseudomembranous colitis
GU: nephrotoxicity, fatal uremia
HEMA: leukopenia, neutropenia
SYST: anaphylaxis, super
infection

PATIENT DATA FROM

YOUR ASSESSMENT
(What data is important to know
before & after giving)
Observe for signs of
anaphylaxis, assess injection site,
obtain cultures before
administration, obtain history
Assess infection, I&O, renal
compromise (excreted by
kidney); VS, allergic reaction
Admin antihistamine if Red Man
syndrome occurs Eval
therapeutic response Teach to
complete entire course; report
sore throat, fever, fatigue, take in
equal intervals ATC to maintain
blood levels
Assess for epigastric pain, occult
blood, platelets Admin
antacids 1 hr before or 2 hours
after famotidine; dilute 2mL
of product (10mg/mL) in 0.9%
NS to total volume of 5-10mL
Push over 2 min to prevent
hypotension
Do not administer if patient
receiving lovenox Bleeding:
gums, petechiae,ecchymosis,
black tarry stools, hematuria,
epistaxis, decrease in Hct, B/P;
May cause mouth or throat
irritation, good to know if
allergic reaction in the past, past
dental history
Assess Renal studies: BUN,
urine creatinine; I&O ratio
Blood studies; CBC, Hct, Hgb,
PT if pt. is on long-term therapy
Hepatotoxicity: dark urine, claycolored stools, yellowing of skin,
sclera, itching, abd. pain, fever,
diarrhea.Ototoxicity; ringing,
tinnitus, roaring in ears
Sound alike/Look alike:
Fentanyl/Sufenta Controlled
Substance Schedule II Assess:
VS after parenteral route, note
muscle rigidity; CNS s,
allergic reactions; respiratory
dysfunction Admin: by inj; give
slowly to prevent rigidity; must
have emergency equipment
available, opioid antagonists, O2
Eval: therapeutic response,
induction of anesthesia
Teach: C&DB, safety measures;

Sodium chloride
0.9% KVO 5mL/hr

Mineral and electrolyte

replacement/supplements
To maintain IV access

ADVERSE REACTIONS
There may be reactions due to
solution or technique of
administration which include air
embolization with stroke, chest
pain and dyspnea, arrhythmia,
hypotension, myocardial
infarction, sepsis, febrile
response, local tenderness,
infection at the site of injection,
venous thrombosis or phlebitis
extending from injection site,
extravasation, fluid overload,
and hypervolemia.
Analysis of Diagnostic Tests

CNS changes
WARNINGS AND
PRECAUTIONS Air Embolism
Remove all air from the syringe
and associated tubing prior to
injection To avoid air embolus
with the associated risk of
stroke, organ ischemia and/or
infarction, and death.

DIRECTIONS:
1.

List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications)
and provide the patient values for each test. Explain why they are pertinent for this patient.

2.

List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased
or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test

WBC

Patient Values
14.78, 19.20, 22.4, 24.6, 24.7, 16.4

9.8, 10.6, 11.1, 9.7, 9.3

Hgb
Procalcitonin

0.12, 0.10, 0.13

WBC: 5.13, RBC: 32, Protein:157

CSF
Urine analysis and culture

normal
negative

Sputum culture
negative

Negative results rules out blood infection as

cause of elevated WBC

Scattered SAH, displaced

mandibular fx, posterior
condylar displacement w/
tympanic temporal fx
bilaterally, Right zygomatic
arch and left maxillary sinus
fx
C5 and C6 fx comminuted fx of
articular pillars and transverse
processes
Acute medial malleolus and distal
fibular diaphysis fx with minimal

Patient has multiple injuries as a result of

being hit by a car on his bicycle and
will be monitored closely for neuro
deficits

Blood culture
CT head

CT spine
Right ankle 3 views

Analysis of Values
The cause of the elevated WBC count is
unknown and more testing is required to rule
out infection. Most likely the cause is the
overall trauma to the patient.
Is the decreased Hgb because the patient is
bleeding or because of the trauma and
healing process? Values should be watched
closely to monitor progression.
To assist in diagnosing bacterial infection and
risk for developing sepsis. Trying to address
cause of meningitis
<0.1 absent <0.5 unlikely
To assist in the differential diagnosis of
infection or hemorrhage of the brain. Results
slightly off due to trauma not infection
Normal value rules out infection of urinary
tract being the cause of elevated WBC
Negative results rules out respiratory
infection as cause of elevated WBC

Patient has multiple fractures of his cervical

spine and got surgery to fuse C5 and C6
Patient broke the bottom half of his right leg
and had surgery to repair the fractures and

displacement of the medial

malleolus fx

was placed in a splint.

Narrative Charting Sample

Patient is a 52 year old male that was struck by a car while riding his bicycle intoxicated. He came into Butterworth ED as a
trauma and proceeded to receive multiple tests showing an array of injuries. Patient had had multiple surgeries to fuse his C5 and
C6 and to reduce the fractures in his right leg. Patient is intubated as a result of his scattered SAHs. Patient is able to follow simple
commands, but is unable to use is left arm. The plan is to extubabte patient in the a.m. and place a trach and PEG tube. Patients
son consented to treatment over the phone by speaking to the performing physician and nurse. Patients current rate of 50mcg/hr of
fentanyl will be reduced to 40mcg/hr and so on to see how the patient tolerates coming off of sedation in preparation for his
procedures tomorrow.