Health History: Patient is a 36 year old female of Caucasian decent. Past medical history, of depression, Bi-polar affective disorder, spinal epidural abscess, paraplegia, anemia associated with acute blood loss, Hepatitis C, poly substance abuse, kidney infection, panic attacks, ectopic pregnancy, staphylococcus infection, protein malnutrition, neurogenic bowel, and neurogenic bladder. Current medical history, patient is a 36 year old female was admitted to Memorial Regional Hospital, complaining of severe back pain that also includes fever and chills. Urine test came back positive for cocaine. Patient was also admitted with right arm abscess at injection site as well as left medial ankle. Patient is also on infectious precautions due to positive
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On the other hand Physical therapy is used to redevelop her strength for transfers, balance, wheelchair mobility, and gait training. Recreational therapy is done to address her leisure activities to decrease her anxiety. Rehabilitation nursing is used to address her bowel and bladder training, teach her bathing, toileting, and how to dress herself as well skin care. Bowel reprogramming was done for neurogenic bowel and rectal toning. In addition the Foley catheter was ordered to improve bladder mobility and retraining. Sequential compression device (SCD’s) and TED hose was also order to prevent Deep vein thrombosis (DVT).
The members of the treatment team that is responsible for the care of this patient are the attending Provider: Ivor Nugent, MD who did the collaborated report from all of the team that is responsible for her care, including Registered nurse; patient care assistant (PCA), certified nursing assistant (CNA), Recreational therapist, Occupational therapist and Physical therapist.
Priority Nursing Diagnosis
Chronic Pain related to T6-11 laminectomy evidenced by patient states back pain of 9 on a scale of 0-10.
Short-term goal: Patient will state a pain of 3 on a scale of 0-10 prior to the end of shift.
Long-term goal: Patient will be pain free and will not need any analgesic to manage pain within 6 months.
Nursing
On the other hand Physical therapy is used to redevelop her strength for transfers, balance, wheelchair mobility, and gait training. Recreational therapy is done to address her leisure activities to decrease her anxiety. Rehabilitation nursing is used to address her bowel and bladder training, teach her bathing, toileting, and how to dress herself as well skin care. Bowel reprogramming was done for neurogenic bowel and rectal toning. In addition the Foley catheter was ordered to improve bladder mobility and retraining. Sequential compression device (SCD’s) and TED hose was also order to prevent Deep vein thrombosis (DVT).
The members of the treatment team that is responsible for the care of this patient are the attending Provider: Ivor Nugent, MD who did the collaborated report from all of the team that is responsible for her care, including Registered nurse; patient care assistant (PCA), certified nursing assistant (CNA), Recreational therapist, Occupational therapist and Physical therapist.
Priority Nursing Diagnosis
Chronic Pain related to T6-11 laminectomy evidenced by patient states back pain of 9 on a scale of 0-10.
Short-term goal: Patient will state a pain of 3 on a scale of 0-10 prior to the end of shift.
Long-term goal: Patient will be pain free and will not need any analgesic to manage pain within 6 months.
Nursing