SAULT COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Care Plan by JOIDA MAE ESPER I. CANONO IEN-ENP

Code Status: FULL CODE VS: BP- 99/63, HR- 69 , RR- 14 , T-36.9 , O2sat-94% Wt: 67.3 kg
Admitting DX : POLYTRAUMA POST FALL Diet: REGULAR IV: N/A LBM: 02-14-23 BG: 5.0
ER AND HSN: OCT 3, 22 ICU: NOV 3, 22 Medical: JAN 6, 23 Rehab: JAN 16, 23 Oxygen: Room Air O2 Sat: 94% Tubes: IFC in situ AND TRACHEOSTOMY
Allergies: NKDA Wound: STAGE II AT COCCYX Dressing: WARM SOAP WATER WASH, APPLY CALMO Isolation: CONTACT

Surgical Intervention: T2-T4 posterior instrumented fusion, T4 laminectomy and T3 partial laminectomy; ORIF Activity: Level C Lift/Transfer: N/A Level of Risk for Falls: MODERATE Braden: AT RISK
AND TRACHEOSTOMY Other: visual impairment, no sensation to both bilat. legs
Coexisting Illness(es): Depression/anxiety, PTSD and severe irritability, Episodic confusion secondary to
complex partial seizure with prolonged postictal phase/psychosis

ASSESSMENT PLANNING
Behaviour/Responses/Findings Nursing Interventions EVALUATION
(Data collection information and
Nursing Diagnosis AMB/AEB Goal
(including time frame)
observations)

Risk for impaired breathing N/A as the problem has The patient will - Assess respiratory function by asking
Subjective: pattern related to maintain adequate the patient to take a deep breath.
not occurred and
impairment of innervation nursing interventions ventilation as Note the presence or absence of
-PMHx of polytrauma post fall at 3 of diaphragm ( C-spine evidenced by the spontaneous effort and quality of
storey building are directed at
fracture of the vertebral absence of respirations (labored, using accessory
- C-spine fracture of the vertebral prevention. muscles).
body C2, C3, C4 ) respiratory distress
body C2, C3, C4 C-1 to C-3 injuries result in complete
and ABGs within
- T2-T4 posterior instrumented
acceptable limits. loss of respiratory function. Injuries at
fusion, T4 laminectomy and T3 partial
laminectomy
C-4 or C-5 can lead to variable loss of
- had 2 aspiration events while on The patient will respiratory function, depending on
medical requiring extensive demonstrate phrenic nerve involvement and
intervention appropriate diaphragmatic function, but generally
behaviors to cause decreased vital capacity and
support the inspiratory effort. For injuries below
Objective: respiratory effort. C-6 or C-7, respiratory muscle
function is preserved; however,
-Pt’s weight- 67.3 kg.
-on tracheostomy
-stage II P.I on coccyx
- on Hydromorphone immediate
release 4 mg 4 times daily, Tylenol
650 mg 4 times daily, Lyrica 50 mg 3
times daily
-Labs: WBC 10.1 RBC 3.62, Hgb 107,
Hct 0.344, K 4.1, Bicarb 33, BUN 5.0,
Creatinine 33, eGFR less than 90, ALT
11, VALPROI 375
V/s: BP- 99/63, HR- 69 , RR- 14 , T-36.9 ,
O2sat-94% on RA
weakness or impairment of
intercostal muscles may impair
effectiveness of cough and the ability
to sigh, deep breathe.
- Auscultate breath sounds. Note
areas of absent or decreased breath
sounds or development of
adventitious sounds (rhonchi).
- Note the strength or effectiveness of
the cough.
Level of injury determines the
function of intercostal muscles and
ability to cough spontaneously or
move secretions.
- Observe skin color for developing
cyanosis, and duskiness.
May reveal impending respiratory
failure, need for immediate medical
evaluation and intervention.
- Maintain patent airway: keep head
in a neutral position, elevate the head
of the bed slightly if tolerated, and
use airway adjuncts as indicated.
Patients with high cervical injury and
impaired gag and cough reflexes
require assistance in preventing
aspiration and maintaining the
patient’s airway.
- Assist with coughing as indicated for
the level of injury (have the patient
take a deep breath and hold for 2 sec
before coughing, or inhale deeply,
then cough at the end of a slow
exhalation). Alternatively, assist by
placing hands below diaphragm and
pushing upward as patient exhales
(quad cough).

- Reposition and turn periodically.

Avoid and limit prone position when
indicated.
Enhances ventilation of all lung
segments, and mobilizes secretions,
reducing the risk of complications
such as atelectasis and pneumonia.
Note: Prone position significantly
decreases vital capacity, increasing
the risk of respiratory compromise
and failure.

- Encourage fluids (at least 2000 mL

per day). Aids in liquefying secretions,
promoting mobilization and
expectoration.

- Assist with the use of respiratory

adjuncts (incentive spirometer, blow
bottles) and aggressive chest
physiotherapy (chest percussion).

- Administer oxygen by an appropriate

method (nasal prongs, mask,
intubation, ventilator).