Brief Patient History
Question Answered step-by-step Brief Patient History Mr. X is a 67-year-old male who is obese. He has a 2-year history of emphysema (100 packs/year history of tobacco abuse in the past) with two recent hospitalizations for pneumonia that required ventilatory support. Mr. X states that he does not want to be placed on a ventilator again and does not want to suffer either. He was involved in a motor vehicular accident (MVA) and sustained blunt trauma to his trunk and lower extremities, with bilateral femur fractures. Although his condition is critical, he is expected to recover. Mr. X received morphine 5 mg by intravenous push in the emergency department, with minimal pain relief; however, he has experienced new-onset confusion. Mr. X’s spouse and children expressed concern about the risk of respiratory depression due to pain medication. They state that they would rather Mr. X experience pain than have him placed on the ventilator again.Clinical Assessment Mr. X is admitted to the critical care unit from the emergency department with blood transfusions in progress. Buck’s traction (5 pounds) has been applied to both lower extremities. He is awake, alert, and oriented to person, time, place, and situation. Mr. X is breathing through his mouth, taking shallow breaths. He complains of right upper quadrant abdominal pain when taking a deep breath. His skin is warm and dry. Mr. X is able to move his toes on command, and lower extremity sensation to touch is intact; however, he is complaining of severe bilateral lower extremity pain with restlessness.Diagnostic Procedures Arterial blood gases: PaO2, 55 mm Hg; PaCO2, 28 mm Hg; pH, 7.35; HCO3−, 24 mEq/L; O2 saturation, 88%. Hematocrit, 24%; hemoglobin, 8 g/dL. Patient reports pain as a 10 on the Baker-Wong Faces Scale. Riker Sedation-Agitation Scale score = 5.Medical Diagnosis Mr. X is diagnosed with a hepatic hematoma and bilateral femur fractures from an MVA.Questions1. What major outcomes do you expect to achieve for this patient?2. What problems or risks must be managed to achieve these outcomes?3. What interventions could be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?4. What interventions could be initiated to promote optimal functioning, safety, and well-being of the patient?5. What technology can be used to monitor this patient and prevent complications?6. What other interprofessional team members are needed to assist with the management of this patient?7. What possible learning needs would you anticipate for this patient?8. What cultural and age-related factors might have a bearing on the patient’s plan of care? Health Science Science Nursing NUR 103 Share QuestionEmailCopy link Comments (0)
