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Health Assessment, Health History, and Nursing Diagnosis for Mr. Clark
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Health Assessment, Health History, and Nursing Diagnosis for Mr. Clark
Admitting Diagnosis: T3 Burst Fracture:
The primary admitting diagnosis for Mr. Clark is a T3 burst fracture, which is a severe injury to the thoracic spine in which the vertebra at the level of the third thoracic vertebra (T3) is broken and fragments have spread into the surrounding tissue. Such a fracture is commonly caused by high-impact trauma, for example an MVA, as in Mr. Clark’s case (Daher et al., 2024). Structural stabilization on the other hand comprises of procedures to realign the spinal bones and fixating them to allow for normal healing and prevent further spinal cord injury. The pathophysiology for this condition is the traumatic disruption of the vertebral structure, which may injure the spinal cord, changes the structural integrity, and affect the transmission of nerve signals below the level of injury.
Secondary Diagnoses:
1. Paraplegia: Mr. Clark was diagnosed with paraplegia caused by an injury to the spinal cord at T3 level. Paraplegia is characterized by the paralysis of the lower limbs while, in the event of a more extensive injury, may be accompanied by paralysis of the abdominal organs and trunk. The biochemistry of paraplegia is that of the disruption of neural pathways in the spinal cord that carry motor and sensory signals from the brain and to the lower body (Dobkin, 2021). In the Mr. Clark case, we have sensory and motor loss which is recorded from the clavicles downward which is a marker of high grade complete spinal cord injury through the involved roots.
2. Neurogenic Bladder and Bowel: Mr. Clark’s experience of incontinence of bowel and bladder is a sign of neurogenic bladder and bowel, the conditions commonly associated with spinal cord injuries. The pathophysiology behind such conditions is the loss of neuronal control over the bladder and bowel and failing to control urination and defecation (Tate et al., 2020). This is due to interruption of the nerve signals that coordinate the muscles and sphincters responsible for these functions.
3. Pressure Ulcer – Stage 3: Mr. Clark has a stage 3 pressure ulcer on his coccyx, which is a major problem. Pressure ulcers, commonly known as bedsores, are caused by the prolonged pressure, which slows down the blood flow to the area. At the third stage, the ulcer is a deep wound which involves the tissue below the skin and hence considerably increases the risk of infection and further problems (Patek & Stewart, 2023). The etiology of pressure ulcers is linked to ischemic damage to the skin and underlying tissues and further compounded by factors including immobility, sensory loss, and nutritional deficiencies.
4. Substance Abuse (Alcohol) and Obesity:
Mr. Clark’s medical history includes both alcohol abuse and obesity, which have a significant impact on his health. Alcohol abuse can cause many systemic conditions that involve liver dysfunction, cardiovascular disease, and neurological impairment, which may make it difficult for him to recover (Patek & Stewart, 2023). Obesity aggravates the already existing pressure on the healing spine, makes mobility and rehabilitation process very difficult and increases the comorbidities such as diabetes and cardiovascular disease.
2. Physical Assessment and Client Interview
· General Appearance and Mental Status: Mr. Clark appears well-groomed, alert, and oriented to time, place, and person. He expresses concerns about his current health status and future independence, indicative of intact cognitive functions but potential emotional distress.
· Neurological Assessment: Examination reveals paralysis and absence of sensation below the clavicles, consistent with a T3 spinal cord injury. Reflexes in the upper extremities are intact, but absent in the lower extremities.
· Cardiovascular System: Heart sounds are regular without murmurs, rubs, or gallops. Peripheral pulses are palpable and equal in the upper extremities but diminished in the lower extremities due to decreased mobility.
· Respiratory System: Breath sounds are normal to auscultation bilaterally. Mr. Clark has a productive cough; however, airway clearance breathing exercises can be harder and can lead to atelectasis.
· Gastrointestinal System: Abdomen is soft, non-distended with no palpable masses. Bowel sounds are audible but may be hypoactive due to neurogenic bowel.
· Genitourinary System: Mr. Clark is incontinent of bladder with Foley catheter in situ, draining unadulterated yellow urine without any signs of infection or hematuria.
· Integumentary System: Stage 3 pressure ulcer located on coccyx noted with thorough wound care. Intact skin elsewhere except for no extra areas of erythema or breakdown.
· Musculoskeletal System: The upper extremities show a full range of movement and strength, whilst the lower extremities show no voluntary movement or muscle tone caused by paralysis.
· Psychosocial Assessment: Mr. Clark complains about his loneliness and fear of being unable to go back to his former life and job. He is without local family support and is fearful about future care and rehabilitation.
Nursing Diagnoses
1. Impaired Physical Mobility related to paralysis of lower extremities as evidenced by inability to move from bed to wheelchair independently.
2. Risk for Impaired Skin Integrity related to sensory loss and immobility as evidenced by existing stage 3 pressure ulcer on the coccyx.
3. Impaired Urinary Elimination (Neurogenic Bladder) related to spinal cord injury as evidenced by incontinence and the need for a Foley catheter.
4. Impaired Bowel Elimination (Neurogenic Bowel) related to spinal cord injury as evidenced by incontinence and the need for routine use of Dulcolax suppositories.
5. Risk for Social Isolation related to physical immobility and lack of immediate family support in the area as evidenced by living alone and family living three states away.
Conclusion
Mr. Clark’s complete care and management need a multidisciplinary approach which includes meticulous medical treatment, watchful nursing care and cooperative rehabilitative efforts. Meeting his complex medical needs includes treatment of physical condition, as well as consideration of his psychological wellness, social support needs, and lifestyle adjustments.
References
Daher, M., Cronkhite, S., Balmaceno-Criss, M., De Varona-Cocero, A., Diebo, B. G., & Daniels, A. H. (2024). Burst fracture treatment caudal to long posterior spinal fusion for adolescent idiopathic scoliosis utilizing temporary lumbo-pelvic fixation with restoration of lumbar mobility after instrumentation removal. North American Spine Society Journal (NASSJ), 17, 100307. https://doi.org/10.1016/j.xnsj.2023.100307
Dobkin, B. H. (2021). Paraplegia and spinal cord syndromes. Bradley’s Neurology in Clinical Practice E–Book, 356.
Patek, M., & Stewart, M. (2023). Spinal cord injury. Anaesthesia & Intensive Care Medicine. https://doi.org/10.1016/j.mpaic.2023.04.006
Tate, D. G., Wheeler, T., Lane, G. I., Forchheimer, M., Anderson, K. D., Biering-Sorensen, F., … & Post, M. W. (2020). Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease. The journal of spinal cord medicine, 43(2), 141-164. https://doi.org/10.1080/10790268.2019.1706033
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