Care Plan

Student: Maya Mendez Date: 10/24/2019

Course: NSG 300CC Clinical Instructor: Professor Yost

Clincial Site: Immanuel Campus of Care – Acute Center Client Identifier: D.N. Age: 76

Reason for Admission: T12 fracture and chronic back pain

D.N was admitted here on October 18, 2019. Patient is admitted to acute center due to a T12 fracture and sustaining multiple falls while at an
independent living center.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Compression fractures of the spine usually occur at the bottom part of the D.N.’s current clinical manifestation includes a pain level of 5 out
thoracic spine (T11 and T12) and the first vertebra of the lumbar spine of 10, chronic back pain with a T12 fracture, with trouble
(L1). Compression fractures of the spine generally occur from too much dysphagia (swalloing) and trouble with aspirations.
pressure on the vertebral body. This usually results from a combination of Dysphagia is reported to be a common secondary complication for
bending forward and downward pressure on the spine. If the bone is too individuals with traumatic spinal injuries. Different etiologies of
weak to hold normal pressure, it may not take much pressure to cause the traumatic spinal injuries may lead to different profiles of
vertebral body to collapse. If the force is too great for the vertebrae to swallowing impairment (Valenzano, Waito & Steele, 2016).
sustain, one or more of them can fracture (Lumbar, n.d.).
Chronic pain persists. Pain signals keep firing in the nervous system for
weeks, months, even years. There may have been an initial mishap,
sprained back, serious infection, or there may be an ongoing cause of
pain, arthritis, cancer, ear infection, but some people suffer chronic pain in
the absence of any past injury or evidence of body damage (Chronic pain,

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

2019).

Assessment Data
Subjective Data: Patient presents with a chief complaint of back pain, specifically a 5 out of 10. Patient indicates that it hurts when the head of
his bed is raised more than 35 degrees or when he tries to swallow any food or liquids.
VS: T : 99.4 degrees F Labs: Diagnostics:
BP: 126/78 CBC: X-Ray – used to determine that there was a fracture on the
spine.
HR: 71 bpm - WBC 5.3
RR: 18 rpm - RBC 3.52 CAT scan – makes sure that the fracture is stable, shows
both bone and soft tissues. Takes sections of the spine so
O2 Sat: 97% - HGB 12.7 they can be examined seperately.
- HCT 35.6
- MCHC 35.7
- MCV 101
- Platelet 199

BMP

- Sodium 12.5
- Potassium 3.4
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 - Chloride 87
- CO2 29
- BUN 3.7
- Creatinine 0.65

Assessment: Orders:
PMH: D.N.’s past medical history is; resolved schizophrenia, - Fall Precautions
hypertension, and atrial fibrillation. Patient currently has active back
- Pain Control with oral medications
pain.
- Physical therapy consult
- Orthopedic surgery consult
Skin: Warm and dry, has multiple bruises on arms and legs.
- Nephrology consult
Neuro: Is alert and cognitively x2 and communication is verbal. - Puree diet
Eye: Pupils are equal, round nd reactive to light. Extraocular - Code Status: DNR
movements are intact, normal conjuctiva.
- Monitor pain every shift
HENT: Normocephalic, normal hearing, oral mucosa is moist. - Meds
Resp: Lungs are clear to ausculation, respirations are non-labored, o Calcium replacements
breath sounds are equal. o Magnesium replacements
Cardio: Normal rate, rgualr rhythm, no murmur, 2+ o Phosphorus replacements
o Potassium replacements
GI: Soft, non-tender, non distended.
o Acetaminophen-oxycodone 325mg - 1 tablet oral Q4th
Musculoskeletal: Normal ROM, tenderness to palpation around T12. o Docusate-senna 1 tablet per oral BID
Psychiatric: Cooperative, appropriate mood and effect. o Polyethylene glycol 17 gm oral daily.
Diet: Puree diet, risk for swallowing and chewing problems, fluid
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restriction is 2,000mL.

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 Medications
ALLERGIES: No Known Allergies

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Calcium replacements 1 Tablet PO QD Replacement of calcium CNS: headache, tingling. Monitor BP, pulse,
in deficiency states. CV: syncope, cardiac and ECG frequently
Essential for nervous, arrest, arrhythmias, throughout
muscular, and skeletal bradycardia. GI: parenteral therapy.
systems. Maintain cell constipation, nausea, May cause
membrane and capillary vomiting. GU: calculi, vasodilation with
permeability. Act as an hypercalciuria. (Vallerand, resulting
activator in the Sanoski & Deglin, 2017). hypotension,
transmission of nerve bradycardia,
impulses and contraction arrhythmias, and
of cardiac, skeletal, and cardiac arrest.
smooth muscle. Essential Transient increases
for bone formation and in BP may occur
blood coagulation. during IV
(Vallerand, Sanoski & administration,
Deglin, 2017). especially in
geriatric patients or
in patients with
hypertension.

Assess IV site for

patency

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Magnesium 1 Tablet PO QD Replacement in deficiency CNS: drowsiness. Resp: Monitor pulse, BP,
replacements states. Resolution of decreased respiratory rate. respirations, and
eclampsia. Essential for CV: arrhythmias, ECG frequently
the activity of many bradycardia, hypotension. throughout
enzymes. Plays an GI: diarrhea. MS: muscle administration of
important role in weakness. Derm: flushing, parenteral
neurotransmission and sweating. Metab: magnesium sulfate.
muscular excitability hypothermia. (Vallerand, Respirations should
(Vallerand, Sanoski & Sanoski & Deglin, 2017). be at least 16/min
Deglin, 2017). before each dose.

Monitor neurologic
status before and
throughout therapy.
Institute seizure
pre- cautions.
Patellar reflex (knee
jerk) should be
tested before each
parenteral dose of
magnesium sulfate.
If response is
absent, no
additional doses
should be
administered until
positive response is
obtained.

Monitor intake and

output ratios.

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Phosphorus 1 Tablet PO QD Phosphate is present in CNS: confusion, listless-
replacements bone and is involved in ness, weakness. CV:
energy transfer and arrythmias, cardiac arrest,
carbohydrate metabolism. ECG changes, absent P
Serves as a buffer for the waves, widening of the
excretion of hydrogen QRS complex with
ions by the kidney. biphasic curve,
hypotension hyperkalemia,
Urinary acidification. ECG changes, prolonged
Increased efficacy of PR interval, ST segment
methenamine. Decreased depression, tall-tented T
formation of calcium waves. GI: diarrhea,
urinary tract stones. abdominal pain, nausea,
(Vallerand, Sanoski & vomiting. F and E:
Deglin, 2017). hyperkalemia,
hyperphosphatemia,
hypocalcemia,
hypomagnesemia. Local:
irritation at IV site,
phlebitis. MS:
hyperkalemia, muscle
cramps; hypercalcemia,
tremors. Neuro: flaccid
paralysis, heaviness of
legs, paresthesias.
(Vallerand, Sanoski &
Deglin, 2017).
Potassium 1 Tablet PO QD Maintain acid-base CNS: confusion,
replacements balance, isotonicity, and restlessness, weakness.
Assess patient for
signs and symptoms
of hypokalemia,
weakness, fatigue,
arrhythmias,
presence of U
waves on ECG,
polyuria, polydipsia
and
hypophosphatemia,
anorexia, weakness,
decreased reflexes,
bone pain,
confusion, blood
dyscrasias,
throughout therapy.
Monitor pulse, BP,
and ECG prior to
and periodically
throughout IV
therapy.
Monitor intake and
output ratios and
daily weight.
Report significant
discrepancies.
Assess for signs and
symptoms of
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 electrophysiologic balance CV: ARRHYTHMIAS, hypokalemia,
of the cell. Activator in ECG changes. GI: weakness, fatigue,
many enzymatic reactions; abdominal pain, diarrhea, U wave on ECG,
essential to transmission flatulence, nausea, arrhythmias,
of nerve impulses; vomiting tablets, capsules polyuria, polydipsia
contraction of cardiac, only, GI ulceration, and hyperkalemia.
skeletal, and smooth stenotic lesions. Neuro: See Toxicity and
muscle; gastric secretion; paralysis, paresthesia. Over- dose.
renal function; tissue (Vallerand, Sanoski &
synthesis; and Deglin, 2017).
carbohydrate metabolism.
(Vallerand, Sanoski &
Deglin, 2017).

325 mg PO Q4th Used for patients re- CNS: confusion, sedation, Assess BP, pulse,
Acetaminophen- quiring around-the-clock dizziness, dysphoria, and respirations
oxycodone management of chronic euphoria, headache, before and
pain. EENT: blurred vision, periodically during
(Vallerand, Sanoski & diplopia, miosis. Resp: ad- ministration. If
Deglin, 2017). Resp depression CV: respiratory rate is
orthostatic hypotension. 10/min, assess level
GI: constipation, dry of sedation.
mouth, choking, GI Physical stimulation
obstruction, nausea, may be sufficient to
vomiting. GU: urinary prevent significant
retention. (Vallerand, hypoventilation.
Sanoski & Deglin, 2017). Dose may need to
be decreased by 25
– 50%. Initial
drowsiness will

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Docusate-senna
Polyethylene glycol
Goal
Client or family focused.
1 Tablet PO BID Treatment of constipation
associated with dry, hard
stools and decreased
intesti- nal motility.
Prevention of opioid-
induced constipation.
Softening passage of
stool. (Vallerand, Sanoski
& Deglin, 2017).
17gm PO QD Treatment of occasional
constipation. Evacuation
of the GI tract without
water or electrolyte
imbalance. (Vallerand,
Sanoski & Deglin, 2017).
Nursing Diagnoses and Plan of Care
Expected Outcome Intervention(s)
Measurable, time-specific, Nursing or interprofessional Provide reason why intervention
reasonable, and attainable. interventions.
Electrolyte imbalances,
dehydration. GI:
abdominal cramps, nausea,
vom- iting, diarrhea.
Derm: rashes. GU: urine
discoloration. (Vallerand,
Sanoski & Deglin, 2017).
Derm: urticaria. GI:
abdominal bloating,
cramping, flatulence,
nausea. (Vallerand,
Sanoski & Deglin, 2017).
Rationale
is indicated/therapeutic.
Provide references.
diminish with
continued use.
Assess for
abdominal
distention, presence
of bowel sounds,
and usual pattern of
bowel function as
well as assess color,
consistency, and
amount of stool
produced.
Assess for
abdominal
distention, presence
of bowel sounds,
and usual pattern of
bowel function as
well as assess color,
consistency, and
amount of stool
produced.
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
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Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Chronic back pain due to T12 spinal fracture
Patient maintains activity
diary and pain-level chart
that rates severity of pain
on a scale of 1 to 10.
D.N.’s pain will decrease
from 5 out of 10.
Secondary Nursing Diagnosis: Risk for swallowing
Patient will not have pain
while swallowing or be at
risk of swallowing.
Patent will develop pain Provide instruction about
management program that amount of pain medication
includes activity and rest needed to control
schedule and medication symptoms, and allow the
regimen. patient to remain active
Patient will state Teach patient how to use
importance of self-care relaxation techniques,
behavior or activites. guided imagery, massage, or
(Phelps, Ralph, & Taylor, music therapy to relieve
2017) pain.
(Phelps, Ralph, & Taylor,
2017)
Patient won’t show Elevate the head of the bed
problems with aspiration. 90 degrees during
mealtimes and for 30
Patient will demonstrate
minutes after the
correct feeding techniques
completion of a meal.
to maximize swallowing.
(Phelps, Ralph, & Taylor, Teach patient and family
2017) members about
positioning, dietary
requirements, and specific
feeding techniques,
including chin down
method. (Phelps, Ralph, &
Taylor, 2017)
Teaching patent about D.N. is not yet ready
medications may help to for discharge, still has a
increase the accuracy of few more weeks but is
dosage necessary to expected to progress
provide pain relief. while here and meet
These methods work as an indented goal.
adjunct to medications,
increases self-help, and
foster independence.
Pending
(Phelps, Ralph, & Taylor,
2017)
You do this after a D.N. is not yet ready for
completion of a meal to discharge, still has a few
decrease the risk of more weeks but is
aspiration. expected to progress while
here and meet indented
These measures allow
goal.
patient to take an active
role in maintaining health.
Patients who experience
delays in the swallowing Pending
trigger usually benefit
from this maneuver, as it
significantly reduces the
risk of food aspiration
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 (Phelps, Ralph, & Taylor,
2017) immediately prior to
deglutition

References

Chronic pain information page. (2019, March 27). Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-pain-

Information-Page

Lumbar compression fractures. (n.d.). Retrieved from https://www.umms.org/ummc/health-

services/orthopedics/services/spine/patient-guides/lumbar-compression-fractures

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA: Wolters

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 Kluwer

Valenzano, T. J., Waito, A. A., & Steele, C. M. (2016). A Review of Dysphagia Presentation and Intervention Following Traumatic

Spinal Injury: An Understudied Population. Dysphagia, 31(5), 598–609. doi:10.1007/s00455-016-9728-4

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

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