0700: The nurse plans a visit to a client who was discharged…
0700: The nurse plans a visit to a client who was discharged from the hospital 1 week ago. The nurse reviews the discharge summary in the medical record and the Nurses’ Notes from the previous home visit done on the day after hospital discharge. Discharge Summary This 32-year-old client sustained a T6 spinal cord injury 3 months ago from a motor vehicle crash that caused paralysis of the lower body. The client was sideswiped by a truck, which caused the car to roll over 3 times and end up in a ditch off the roadway. The client was pinned in the car, and the front end and side of the car crushed the lower half of their body. The client was hospitalized for 3 months. During hospitalization, emergency treatment was administered, and once stabilized, the client was monitored for complications. The client received rehabilitative therapy including PT and OT, and home care services were initiated for discharge. The client is married, and the client’s spouse stays at home caring for their two children, ages 7 and 10. Prior to the injury, the client was a forklift driver at an industrial manufacturing company. The client has no previous medical history, does not take any medications, does not smoke, and drinks occasionally at social gatherings. Nurses’ Notes One day post-discharge: Client alert and oriented. Sitting up in wheelchair. Using a transfer board, with spouse’s assistance, to get out of bed to the wheelchair. Reports sitting in the wheelchair all day. Fair appetite and is drinking fluids. Complains of tiredness and falling asleep in the wheelchair during the day. Reports sweating during the night, which wakes the client; once repositioning to the side, the sweating stops but has difficulty falling back to sleep. Has muscle spasms in the lower body. No headache. Reports self-catheterizes every 6 hours. Last bowel movement was on the day of hospital discharge. VS: T = 98.6°F (37.0°C); HR = 86 BPM; RR = 18 bpm; BP = 120/78 mm Hg. Today 1000: The nurse arrives at the client’s home and after introductions performs a focused assessment. VS: T = 99.2°F (37.3°C); HR = 59 BPM; RR = 18 bpm; BP = 150/90 mm Hg. Alert and oriented. Poor appetite over the last few days and is nauseated. Has tiredness and continued sweating during the night. Muscle spasms in the lower body worsening and was incontinent once during the night. Feeling is getting the flu because of nausea, nasal stuffiness, and pounding headaches. States last bowel movement was 4 days ago. Choose the assessment finding listed below that are expected (for condition), abnormal finding (for condition), or not relevant (not important) for the patient’s plan care and for what he is experiencing at this time. Answers may be used more than once.
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