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Patient riding motorcycle. Scan showed cervical spine fracture. Treatment Venodynes on the legs. What could be the nursing notes?

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Practicing since : 1998
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Question: What is the nursing process, care plan in this case, what is appropriate nursing diagnosis, interventions, goals and Evaluation. What are the dietary/nutrition implication in this situation?

patient was riding a motorcycle when he got into an accident.
Differential dx: cervical spine fracture, HPI:ct scan = fractured ribs-0000. presents with Crepitus, traumatic pneumothoraxsignificant pain on right upper quandrant. RT, PTX, RT Scapula FXunaware of previous renal problems. pain 8/10. BP=154/106 on admission currently 118/72, other VS =normal,
Treatment: Venodynes on the legs, Pain control on PCA, has peripheral IV
Labs: Bhb/hct=13.8/40.4; lymphocytes=14.6;co2=23, glucose=406, ast/alt=76/63;urine ketones=trace

1. What would a concept map for this diagnosis look like. I would like to have a concept map of the connection of all these issues.
appetite seems to be good eating everything and denies constipation. denies labored breathing.
2. what are the nursing notes.
Posted Wed, 10 Jul 2013 in Lung and Chest disorders
Answered by Dr. Sandhya Manorenj 4 hours later

Thank you for writing in.

I have gone through the history and the reports.

Based on details he has the following problems

1) Fractured multiple ribs with surgical emphysema( crepitus) and pneumothorax

2) To rule out cervical spine fracture

3) Right upper quadrant pain

4) Raised blood sugar (406) with urine ketones trace indicates Diabetic ketoacidosis

5) Mild elevation of liver enzymes (ast/alt)

I would suggest the following in addition to venodynes ,pain controls,and peripherals IV

1) Cervical hard collar in-view of suspecting cervical fracture, and order CT cervical spine

2) Insulin administration , and hydration with saline ,inorder to correct diabetic ketoacidosis. Monitor blood sugar and electrolyte and urine output

3) Diabetic diet (no added sugar and low calorie diet) and renal diet low protein diet in view of previous renal problem.We need to know his urea and creatine levels and urine output also. I would refer to dietitian for planning diet

4) injury to XXXXXXX organs in view of right upper quadrant pain and treatment to be planned according to reports and also to see for kidney size inview of previous renal problem

6) I would refer to chest physician for pneumothorax .

7) Propped up nursing care with breathing exercise .

Hope, I have answered your query,If you are satisfied with my answer, please do rate my answer after our discussion.Please get back if you require additional information.


Dr Sandhya Manorenj

Above answer was peer-reviewed by
Follow-up: Patient riding motorcycle. Scan showed cervical spine fracture. Treatment Venodynes on the legs. What could be the nursing notes? 17 hours later
- denies renal history of disease.
-Urine glucose was 1000
-BUN =14
-Creatinine = 0.76
-No nausea or vomiting why zofran medication/ antiemetic treatment. no hx of chemotherapy either.
-What is nursing diagnosis for crepitus
What is nursing diagnosis for pneumothorax
what is nursing diagnosis for blood sugar 406
nursing interventions and goals.
Answered by Dr. Sandhya Manorenj 1 hour later

Nursing diagnosis for crepitus

Crepitus is the crackling or popping sensation experienced under skin and joint due to the presence of air in subcutaneous tissue.It is felt by keeping the hand over the site of injury.Swelling seen at the site while inspecting and felt crackling on palpation.
Monitor for increase or decrease of crepitus.(plan).To observe for chest movement, breathing difficulty, saturation and plan accordingly.To inform doctor if deterioration of saturation occurs.

Nursing diagnosis for pneumothorax

Pneumothorax is the abnormal collection of air or gas in the pleural space that separates the lung from the chest wall and which may interfere with normal breathing.It can be primary or secondary.In primary there is no apparent lung disease.In secondary underlying lung disease seen.Trauma lead to injury to lung or fracture rib leading to escape of air into pleural cavity(pneumothorax)

Watch for chest movement, respiration rate, saturation and chest pain.Need to inform physician if shortness of breath occurs and saturation falls.Chest tube insertion is the intervention and goal is to maintain normal chest movement and saturation.

Nursing diagnosis for blood sugar 406

Blood sugar is raised then normal which has to be kept in normal range to prevent further complications like dehydration secondary to diabetic ketoacidosis, to prevent infection.
Educate caretakers about diabetic diet and cleanliness, regular sugar testing and adjust insulin after consulting physician.
To alarm the doctor if low (less than 60mg), and high (>300 mg)blood sugar.

Watch for high blood sugar signs like air hunger, acidotic smell, uneasiness. Watch for hypoglycemia symptoms like drowsiness, cold extremities, sweating profusely,immediately check blood sugar if less to start glucose solution orally ,glucose biscuits ,inform doctor and start glucose drip.
Goal is to maintain fasting blood sugar of less than 110mg/dl and postprandial 140 mg/dl.

Diet required is diabetic ,high protein diet

Hope I have answered your query

Above answer was peer-reviewed by
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