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Mr. Danny Smith is a 32-year-old male paraplegic who has been admitted to your floor for unexplained weakness.
Interview Data
Mr. Smith states that he became a paraplegic when he was 19 years old after a “diving accident”. He states that he lives with his parents but is mostly independent and needs minimal assistance. Mr. Smith states that for the past month, he has experienced a “loss of appetite and generalized weakness”. States he has engaged in very little activity over the past couple of months. Mr. Smith states that his parents insist that he be seen by his doctor. Mr. Smith states his mother and father keep telling him that he is depressed and that this conversation leaves him feeling very angry. He has no other medical problems at this time and no known allergy to medications.
Examination Data
VS: B/P = 118/72; R = 18; P = 76; T 99.6F; O2 Sats = 98%; Pain = 0
Alert, thin, white male with flat affect lying in a supine position. Height reported as 6’2”; weight 153#. Slight foul odor noted on examination.
Skin: Pale. No bruising; no skin discoloration. Presence of Stage 2 skin breakdown involving the epidermis over the left greater trochanter and sacrum.
Hair: Full thick hair distribution on head.
Abdomen: Active bowel sounds noted in all quadrants. Abd soft, nondistended; nontender.
Musculoskeletal: Paralysis, atrophy to both lower extremities; upper extremities fully functional.
1. Is there any additional history data that you wish to have in your investigation of the patient’s complaint?
2. Is there any additional physical exam you want to do in your physical assessment of Mr. Smith?
3. Identify abnormal vs. normal data in the report.
Abnormal Normal
4. Discuss risk factors for the following problems.
a. Pressure ulcer
b. Depression
c. Mal-nutrition
5. Identify appropriate referrals to be considered for Mr. Smith.
6. Identify three priority nursing diagnosis appropriate for Mrs. Smith at this time.
7. Outline and disculuvss the staging of Pressure Ulcers.
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