Kim Johnson KARDEX

Date Laboratories Blood Request/Blood Components

Blood Type:

Date Ordered DIAGNOSTICS

Blood Transfusion History

Date Ordered Surgical and Other Special Procedures

Attending Physician: Chief Complaints: Diagnosis/Impression/Operations:

Paraplegia
Thoracic 8th spinal cord injury
CO- Anesthesiologist:
DATE DATE CONSULT
MANAGE
Anesthesia:
Intra Op Monitoring:
CP Clearance:
Abdominal Girth:
Post Op Site/Dressing:
 Weight:
IV Site/ Tubing Due:
INTRAVENOUS FLUIDS
Date Bottle No. IVF Incorporation Rate Remarks

Diet: SPECIAL ENDORSEMENT

Regular, High Fiber
Vital signs every 8 hours
ALLERGIES: ACTIVITIES: Intake & output every 8 hours
PRECAUTION: Out of bed to chair Anti-embolism stockings
Bladder management program:
Intermittent catherization q4 hours
O2: 2Lpm via NC OTHER ATTACHMENTS:
Bladder scan before catheterization
TRACHEOSTOMY:
NGT FEEDING:
FOLEY CATH:
CYSTOLYSIS:
DRAINS:
ROOM: Admission Service: Name: Age: Sex Religion: Birthdate:
Date/Time: SURG JOHNSON, KIM 26 :
F

Activity 3 : THE PATIENT

 Patient’s Data:
NAME: Kim Johnson
Age: 26 years old
Date of Birth: 5/2/1995
Height: 168 cm
Weight: 60 kg
Chief Complaint: Spinal Cord Injury
Admission Date: 12/15/2021

Laboratory and Diagnostic Test: (Results were not shown on the Virtual Simulation)
Drug Study
Generic/ Classification Action Indication Route & Adverse Contraindicatio Nursing Responsibilities
Trade Dosage Effects n
Name
Enoxapari Anticoagulants Potentiates the used for as 40 mg bleeding Active major Monitor symptoms of DVT
n , inhibitory effect prophylaxis subcutaneousl elevation of bleeding,
Cardiovascular of antithrombin treatment of deep y each day, serum thrombocytopen In patients with DVT, watch
; on factor Xa and vein thrombosis initiated 9-15 aminotransferas ia with for signs of pulmonary
Anticoagulants thrombin. (DVT), which may hours es antiplatelet
embolism.
, Hematologic Therapeutic lead to pulmonary preoperatively, fever antibody in
Effects: embolism (PE) in and continued local site presence of
Prevention of patients for 10 days or reactions enoxaparin or Assess for signs of bleeding
thrombus undergoing up to 35 days low blood heparin and hemorrhage, including
formation. abdominal postoperatively platelet count bleeding gums, nosebleeds,
surgery, hip nausea Hypersensitivity unusual bruising, black/tarry
replacement anemia to enoxaparin, stools, hematuria, and a fall
surgery (during bruising heparin, pork in hematocrit or blood
and following irregular, rapid products, or pressure.
hospitalization), heart rate (atrial other
knee replacement fibrillation) ingredients Assess peripheral edema
surgery and in heart failure
using girth measurements,
 medical patient excess fluid in volume displacement, and
who are at risk for the lungs measurement of pitting
thromboembolic (pulmonary edema
complications due edema)
to severe pneumonia
Monitor signs of anemia,
restricted mobility shortness of
during acute breath
including unusual fatigue,
illness. confusion shortness of breath with
diarrhea exertion, bruising, and pale
blood in the skin. Notify physician or
urine nursing staff immediately if
these signs occur.

Assess dizziness that might

affect gait, balance, and
other functional activities

Be alert for acute arterial or

venous thrombosis caused
by heparin-induced
thrombocytopenia (HIT).

Docusate Laxatives, Docusate is a used to treat PO (Adults EENT: throat Hypersensitivit Monitor any rashes or other
Sodium Stool stool softener. occasional and Children irritation. GI: y; Abdominal abnormal skin responses.
Softener It works by constipation. >12 yr): 50– mild cramps. pain, nausea, Report excessive or
increasing the Some 400 mg in 1– Derm: rashes. or vomiting, prolonged skin reactions to
amount of medications and 4 divided especially the physician.
water the stool conditions can doses. when
absorbs in the make associated Instruct patient how to
gut, making constipation PO (Children with fever or breathe and avoid straining
the stool softer more likely. 6–12 yr): 40– other signs of during bowel movements to
and easier to 150 mg in 1– an acute prevent a Valsalva
pass. 4 divided abdomen. maneuver.
 doses.
Advise patient to avoid
PO (Children overuse of laxatives.
3–6 yr): 20– Encourage patient to use
60 mg other forms of bowel
regulation, such as
increasing fiber and bulk in
the diet, increasing fluid
intake, and regular exercise.

Advise patient to report

other troublesome side
effects such as prolonged or
severe throat irritation or
abdominal cramps.
Omeperaz antiulcer Binds to an GERD/ 40mg Orally CNS: Hypersensitivit Monitor improvements in GI
ole agents enzyme on maintenance of dizziness, y; Metabolic symptoms (gastritis,
gastric parietal healing in drowsiness, alkalosis and heartburn, and so forth) to
cells in the erosive fatigue, hypocalcemia help determine if drug
presence of esophagitis. headache, (Zegerid only). therapy is successful.
acidic gastric Duodenal ulcers weakness. CV:
pH, preventing chest pain. GI: Assess dizziness that might
the final abdominal affect gait, balance, and
transport of pain, acid other functional activities
hydrogen ions regurgitation,
into the gastric constipation, Monitor other CNS side
lumen. diarrhea, effects
flatulence,
nausea, Monitor any chest pain and
vomiting. attempt to determine if pain
Derm: itching, is drug induced or caused
rash. Misc: by cardiovascular
allergic dysfunction
 reactions.
In cases of NSAID-induced
gastritis, implement
appropriate manual therapy
techniques, physical agents,
and therapeutic exercises to
reduce pain and decrease
the need for aspirin and
other NSAIDs.
Oxybutinin urinary tract Inhibits the Urinary CNS: Hypersensitivit Monitor signs of urine
antispasmodi action of symptoms that dizziness, y to the drug retention (difficult urination,
cs acetylcholine may be drowsiness, painful or distended
at associated with agitation, abdomen). Excessive
postganglionic neurogenic confusion, urinary retention may
receptors. Has bladder, hallucinations, require dose adjustment by
direct including headache. physician.
spasmolytic Frequent EENT: blurred
action on urination, vision. CV: Assess heart rate, ECG,
smooth Urgency, tachycardia. and heart sounds,
muscle, Nocturia, Urge GI: especially during exercise
including incontinence. constipation,
smooth muscle Overactive dry mouth, Be alert for decreased
lining the GU bladder with nausea, sweating and increased
tract, without symptoms of abdominal body temperature
affecting urge pain, diarrhea. (hyperthermia), especially
vascular incontinence, GU: urinary during exercise. Notify
smooth urgency, and retention. physician of a prolonged or
muscle. frequency. Derm: persistent elevation in body
decreased temperature.
sweating,
transdermal Monitor changes in mood
only: and behavior, including
application site confusion, agitation, and
 reactions. hallucinations. Notify
Metab: physician if these changes
hyperthermia. become problematic.

Assess dizziness that might

affect gait, balance, and
other functional activities

Monitor transdermal
application site for pain,
swelling, and irritation.
Report prolonged or
excessive reactions to the
physician.

When appropriate,
implement pelvic floor
muscle strengthening
activities and other
therapeutic exercises to
help maintain bladder
control.

NCP
Nursing Diagnosis Desired Outcomes Action/Intervention Rationale Evaluation
Impaired Physical After Nursing Independent: After Nursing
Mobility related to Interventions, the patient Maintain affected joint in prescribed Provides for stabilization of Interventions, the patient
Decreased muscle will be able to: position and body in prosthesis and reduces risk of was able to:
mass/strength as alignment when in bed. injury during recovery from effects
evidenced by limited of anesthesia.
range of motion; Increase strength and Increase strength and
difficulty turning function of affected and Medicate around the clock, or Adequate analgesia is a priority to function of affected and
compensatory body parts sufficient time before procedures decrease pain, reduce muscle compensatory body parts
and activities, so that client is able to tension and spasm, and facilitate
Move about environment participate. participation in therapy. Move about environment
safely. safely.
Turn on unoperated side using Prevents dislocation of hip
Verbalize understanding of adequate number of personnel prosthesis and prolonged skin Verbalize understanding
individual situation and and maintaining operated extremity in and tissue pressure, reducing risk of of individual situation
safety measures. prescribed alignment. Support position tissue ischemia and and safety measures.
with pillows and wedges. breakdown.
Demonstrate techniques Demonstrate techniques
and behaviors that enable Demonstrate and assist with transfer Facilitates self-care and client’s and behaviors that enable
resumption of activities. techniques and use of independence. Proper transfer resumption of activities.
mobility aids, such as a trapeze, techniques prevent shearing
Maintain position of walker, crutches, or canes. abrasions of skin and falls. Maintain position of
function as evidenced by function as evidenced by
absence of contractures Collaborate with physical and Client will require individualized absence of contractures
occupational therapists and activity and exercise program,
rehabilitation specialist. ongoing assistance with movement,
strengthening, and
weight-bearing activities for an
extended period of time, as
well as use of adjuncts, such as
walkers, crutches, canes, elevated
toilet seat, pickup sticks, and so on.

Reduces skin and tissue pressure;

 limits feelings of fatigue and
Provide foam or flotation mattress. general discomfort

Risk for Infection After Nursing Independent: After Nursing

Interventions, the patient Emphasize and model proper hand- Prevents spread of bacteria and Interventions, the patient
will be able to: washing technique. cross-contamination. was able to:

Be free of Infection Maintain aseptic technique in dressing Reduces risk of healthcare- Be free of Infection
changes and invasive procedures. associated infection.
Achieve timely wound Achieve timely wound
healing free of signs of Inspect surgical incisions and invasive Early detection of developing healing free of signs of
local or generalized line sites for erythema and purulent infection provides for prevention local or generalized
infectious process. drainage. of more serious complications. infectious process.

Encourage frequent position changes, Promotes mobilization of

deep breathing, coughing, and use of secretions, reducing risk of
respiratory adjuncts, such as incentive pneumonia.
spirometer.

Provide routine catheter care and Prevents ascending bladder

provide or assist with good perineal infections.
care. Remove catheter as early as
possible.

Encourage client to drink acid-ash Maintains urine acidity and

juices, such as cranberry. prevents bacteria from adhering to
the bladder wall to retard bacterial
growth.
 Reduces bacterial or fungal
Apply topical antimicrobials or colonization on skin; prevents
antibiotics, as indicated. infection in the wound.

A prophylactic antibiotic regimen is

Administer IV antibiotics, as indicated usually standard in these
clients to reduce risk of
perioperative contamination and
peritonitis.

Ancipatory Grieving After Nursing Independent: After Nursing

related to Interventions, the patient
Perceived/actual loss will be able to: Identify signs of grieving (shock, Patient experiences many Express feelings
of physio- denial, anger, depression). emotional reactions to the injury
psychosocial well- Express feelings and its actual or potential impact on Begin to progress
being as evidenced by life. through recognized
expression of distress Begin to progress through stages of grief, focusing
and sadness. recognized stages of grief, Note lack of communication or Shock is the initial reaction on 1 day at a time.
focusing on 1 day at a emotional response, absence of associated with overwhelming
time. questions injury.

Provide simple, accurate information Patient’s awareness of surroundings

to patient and SO regarding diagnosis and activity may be blocked
and care. initially, and attention span may be
limited.

Encourage expressions of sadness,

grief, guilt, and fear among patient, Knowledge that these are
SO and friends. appropriate feelings that should be

Assist patient and SO to verbalize
feelings about situation, avoiding
judgment about what is expressed.
Note loss of interest in living, sleep
disturbance, suicidal thoughts,
hopelessness. Listen to but do not
confront these expressions. Let patient
know nurse is available for support.
Consult with and refer to psychiatric
nurse, social worker, psychiatrist,
pastor.
DISCHARGE PLAN
expressed may be very supportive
to patient and SO.
Important beginning step to deal
with what has happened. Helpful in
identifying patient’s coping
mechanisms.
Phase may last weeks, months, or
even years. Acceptance of these
feelings and consistent support
during this phase are important to a
satisfactory resolution.
Patient and SO need assistance to
work through feelings of alienation,
guilt, and resentment concerning
lifestyle and role changes.
 METHODS NURSING GOAL NURSING ORDER RATIONALE
Upon discharge, the patient Encourage patient to take her/his medication on time and It is necessary for managing chronic
would be able to understand to follow the doctor’s instructions. illnesses, treating temporary conditions,
MEDICATION his/her responsibility to take and overall long-term health and well-
medicine as prescribed by the being to take your medicine as prescribed
doctor. or medication adherence. This also
reduces the number of painful crises from
sickling blood cells.
Upon discharge, the patient Instruct patient to avoid very strenuous exercise strenuous physical activity increases
will be able to participate in blood flow and can lead to serious
EXERCISE non-straining exercises. Learn complications including heart problems
proper techniques and body and episodes of severe pain known as
mechanics. vaso-occlusive crises.
Upon discharge, the patient Encourage patient to complete therapies that is Increase chances for treatment and cure,
will be able to comply orders recommended by the physician for his/her condition. limit risk of complications by closely
THERAPY of the doctor and follow the monitoring existing conditions and
therapy regimen Increase lifespan and improve health
recommended.
Upon discharge, the patient Teach patient the proper hand washing and instruct patient Common illnesses, can quickly become
HYGIENE will be able to understand the to practice good body hygiene all the time. dangerous for a person with sickle cell
importance of proper Instruct the patient, family, and other caretakers to wash disease. The best defense is to take simple
handwashing and good body their hands with soap and clean water many times each steps to help prevent infections. Washing
hygiene. day. If you don’t have soap and water, you can use gel your hands is one of the best ways to help
hand cleaners with alcohol in them. prevent getting an infection.
Upon discharge, patient will Encourage patient to visit his/her doctor for regular check- Follow up check-up tend to decrease the
be able to understand the ups. Encourage patient and their families to communicate chance of getting sick. Promptly classify
OPD importance of regular regularly with health care providers. potentially life-threatening health
checkups and communication problems or diseases. Increase care and
with health care provider. cure prospects.
Upon discharge, the patient Encourage patient to drink 8 to 10 glasses of water every According to experts, people who have
will be able to follow day and eat healthy food. Try not to get too hot, too cold, undergone surgery have greater than
DIET recommended diet by the or too tired. average needs for both calories and
doctor. Encourage the patient to eat a balanced diet that includes a micronutrients.

Upon discharge, the patient
SPIRITUAL will be able to express and
integrate meaning of purpose
of life.
variety of healthful foods from all major food groups and
oils can provide the body with energy, fibre, vitamins,
minerals and other essential nutrients.
Pray for the patient. And allow patient privacy and a quiet Prayer improves clinical outcomes and
place for prayer provides a sense of spirituality and well-
being.