Fundamentals of Professional Nursing

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ProjectPart21.docx

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Project-inst.docx

Module 07 Content

In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:

Health Assessment, Health History, and Nursing Diagnosis

A brief medical/health history

Summary of laboratory diagnostic results related to the illness/condition and what they mean

Summary of a head to toe physical assessment

Your nursing diagnosis

Group2scenario1.docx

Course Project Case Study

Based on the following information, students will complete the course project in their assigned groups.

Group 2

2. Mr. Clark is a 26 Caucasian male who was admitted to the rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst fracture after a MVA and the site was surgically stabilized. He is paralyzed in his lower extremities and has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure ulcer to his coccyx. Medical history includes substance abuse (alcohol) and obesity.

Mr. Clark is single and lives alone in a second story apartment. His parents live three states away and he has no relatives in the area. He is a seasonal construction worker, denies any religious affiliation and speaks English.

Orders include:

Regular diet

Ensure high protein shake BID

Foley cath to dependent drainage

Dulcolax suppository every 3 days rectally

Baclofen 5mg PO QID

Midodrine 10 mg PO at 0800, 1300 and 1800

Sertraline 100mg PO daily

Hydrocodone 5/325 q 6 hours for moderate to severe pain

PT, OT TID, 5 days per week

Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily

Cervical collar when OOB

Transfer with sliding board per PT

Full resuscitation