Question

Scenario TW. is a 22-year-old is now at the emergency department (ED) with a suspected T5-T6 fracture with paraplegia. Iman who fell 50 feet froma chairlift while skiing and landed on hard-packed snow. He Chart View Physician's Orders Insert Foley catheter ECG monitoring Immobilize the cervical spine Oxygen at 4 L per nasal cannula Initiate two large bore IVs Neurologic assessment every hour Apply warming blankets as needed 1. Describe a plan for implementing these physician's orders 2. What are the nursing priorities at this time? 3. Which assessment would you complete first? a. Assessing ability to move the extremities Determining pupil response to light c. Auscultating breath sounds d. Testing the peripheral reflexes Oserved.

Answer 1

1.The plan of the physician can be initiated in the following way

• The patient has to made comfortable and immediately a neurological assessment ,physical examination from had to toe to be done.The oxygen has to be administered to prevent the patient from landing up in hypoxia or hypoxemia.Followed by not mobilizing the patient unnecessary and inserting the line and doing an ECG.
• To prevent the patient from hypothermia
• To maintain intake and output of the patients
• To prevent patient from any cerebral edema and maintaining consciousness

2.The nursing priorities for this patient are

• Assess the patients airway, breathing, circulation, and disability
• Monitor vital signs and administer oxygen which should be the first intervention for this patient
• Assess for neurological status of the patient
• Make the patient warm with the help of blanket
• Meanwhile insert two IV bores on both hands,ECG to be done
• Next the patient has to be inserted a foleys catheter to avoid incontinence, bed wetting etc.,
• Perform neurological assessment every hourly

3.The patient vitals has to be assessed first because without respiration the patient will land up in brain dead in few minutes.This can be followed by checking the size of pupil reacting to light ,assess for injury in extremities and finally reflexes

Ans:C.Ausculting breath sounds