Assessment

Percussion

The patient’s documentation did not include detailed percussion findings. Generally, percussion is used to assess underlying structures by evaluating the sounds produced. Tympani, a drum-like sound, is commonly heard over hollow organs such as the stomach, whereas dullness, a muffled sound, is detected over solid organs like the liver and spleen. This assessment helps in identifying organ size, presence of fluid, or abnormal masses.

Auscultation

The patient’s bowel sounds were recorded as normal, reflecting appropriate frequency and intensity. Breath sounds were generally clear; however, diminished sounds at the bases of the lungs were noted, suggesting reduced ventilation in these areas. This may indicate a need for further respiratory evaluation to rule out conditions like atelectasis or pleural effusion.

Neurological Exam

The patient demonstrates orientation to person, place, and time, indicating preserved cognitive function. A gross examination of cranial nerves II through XII shows intact neurological function. Upper extremity reflexes are normal (graded 2+), while lower extremity reflexes are absent, consistent with paraplegia. The patient exhibits paralysis and lack of sensation below the T4 dermatome, aligning with a spinal cord infarction diagnosis.

Pathophysiology

Functional Changes

The fracture of the extremity limits mobility due to structural compromise of the bone and surrounding tissues. The body’s inflammatory response may increase blood flow, causing redness, warmth, and pain in the affected area unless masked by the type of fracture. These changes are essential indicators for monitoring healing and identifying complications such as infection or improper alignment.

Inability to Support the Body

The T4–T5 spinal fracture significantly affects weight-bearing ability and overall mobility. Disruption of nerve pathways interferes with motor signal transmission, preventing the patient from performing essential movements such as standing or walking. This necessitates careful management, including immobilization, supportive devices, and physiotherapy interventions.

Reflection

Communication

Active listening is essential to address the patient’s concerns effectively and strengthen the therapeutic relationship. Using culturally sensitive communication, eye contact, and appropriate non-verbal strategies enhances patient engagement and ensures that care is tailored to the individual’s preferences.

Safety/Infection Control

Preventive measures are critical to avoid complications such as deep vein thrombosis (DVT), muscle atrophy, delayed healing, and pressure ulcers. Infection control practices, including strict hand hygiene, proper catheter management, and regular monitoring of the incision site, are vital to ensure optimal recovery and patient safety.

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

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–S103.

NR 226 RUA Fundamentals Patient Care