NR 226 RUA Fundamentals Patient Care

Name

Chamberlain University

NR-226: Fundamentals – Patient Care

Prof. Name

Date

Assessment

Component	Description
Percussion	The patient documentation lacks specific information regarding percussion. Typically, percussion evaluates sounds such as tympani (drum-like) over hollow organs and dullness (muffled) over solid organs like the liver and spleen.
Auscultation	Bowel sounds are described as normative, indicating normal frequency and intensity. Breath sounds are clear, with diminished sounds at the lung bases, suggesting reduced air entry in those areas.
Neurological Exam	The patient is oriented to person, place, and time, showing intact cognitive function. A gross assessment of cranial nerves II-XII is intact. Upper extremity reflexes are normal (graded 2+), but lower extremity reflexes are absent, expected in paraplegic cases. Paralysis in lower extremities with no sensation below the T4 dermatome, consistent with spinal cord infarction.

Pathophysiology

Component	Description
Functional Changes	Due to the fractured extremity, the patient has a reduced ability to move it, as bone structure and surrounding tissues are compromised. The inflammatory response increases pain and blood flow to the area, possibly causing redness and warmth unless obstructed by fracture type.
Inability to Support the Body	The T4-T5 fracture prevents the body from bearing weight, impairing walking ability. Nerve disruption affects motor signals, preventing necessary body movement.

Reflection

Component	Description
Communication	Employing active listening to address D.M.’s concerns and needs, strengthening therapeutic relationships. Non-verbal strategies like eye contact and culturally sensitive communication will be used to respect D.M.’s preferences.
Safety/Infection Control	Measures for DVT, muscle atrophy, decreased healing, and pressure ulcer prevention will be implemented, along with infection control practices, such as diligent hand hygiene and catheter care. Regular monitoring for signs of infection at the incision site will support optimal recovery.

References

Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing, 46(12), 36-41. https://doi.org/10.1097/01.NURSE.0000504674.19099.1d

Santos, C., Almeida, M., & Lucena, A. (2016). The Nursing Diagnosis of risk for pressure ulcer: content validation. Revista Latino-Americana de Enfermagem, 24, e2693. https://doi.org/10.1590/1518-8345.0782.2693

NR 226 RUA Fundamentals Patient Care

Suarni, L., Nurjannah, I., & Apriyani, H. (2015). Nursing and collaborative diagnoses on perioperative with and without using six steps of diagnostic reasoning methods. International Journal of Research in Medical Sciences, 3(Suppl 1), S97-103.