Eric Smith is a 17 year old male who was involved in a fight with another teenag

Question

Eric Smith is a 17 year old male who was involved in a fight with another teenager. During the fight, the alleged teenager picked up Eric and threw him to the ground. Eric landed on his neck, attempted to get up, but was unable to move. Eric stated that he was unable to move and witnesses called 911. The paramedics responded immediately, applied a cervical collar, placed him on a transfer board, and transported him to the Harper Medical Center emergency department.

Subjective Data:

·       “I can’t move my legs”.

·       “I landed on my neck”.

Objective data:

              Physical Examination

·       Cardiovascular: B/P - 80/60        AP – 42/regular               RR – 24/min O2 sat – 95% Carotid pulse felt but weak radial and femoral pulse palpated - 1+/1+

·       Temperature:    94.2

·       No anal sphincter tone present.

·       Ecchymosis noted on right upper arm and scapular area

·       Abrasions noted on face, right arm and back

·       No movement, sensation or pain noted in right or left leg

·       No movement, sensation or response to painful stimuli bilaterally in upper extremities.

Diagnostic Studies:

              CT scan reveals fracture in C5

Laboratory values:

              All labs within normal limits

Type and crossmatch:    B negative          Antibody screen – negative

1.           Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is ______________________________________________. What should the triage nurse do next?

2.           What is the data obtained from the primary assessment?

3.           What is the data that is obtained from the secondary assessment?

4.           What is the diagnosis that the nurse suspects and why does it occur? Interpret and explain all the data presented and its significance.

5.           What are some other causes of this diagnosis and what is your role in preventing it in other patients?

6.           What are the initial nursing responsibilities?

7.           What nursing assessments are essential and at what frequency should they be performed?

8.           List and prioritize three nursing diagnoses for this patient.

9.           What are some other collaborative problems that may occur?

10.         Document your findings on the flow sheet and also document your findings using narrative format

Explanation / Answer

1. The triage nurse deems that this is a cervical bone fracture. The triage nurse should immobilise the patient and provide oxygen therapy.
2. The data obtained by the primary assessment are vital signs, physical examination.
3. The data obtained by secondary assessment are laboratory values and CT scan.

Related Questions

Navigate

• Browse (All)
• Browse E
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.