Eric Smith is a 17 year old male who was involved in a fight with another teenager
Eric Smith is a 17 year old male who was involved in a fight with another teenager. During the fight, the alleged teenager picked up Eric and threw him to the ground. Eric landed on his neck, attempted to get up, but was unable to move. Eric stated that he was unable to move and witnesses called 911. The paramedics responded immediately, applied a cervical collar, placed him on a transfer board, and transported him to the Harper Medical Center emergency department.
· “I can’t move my legs”.
· “I landed on my neck”.
· Cardiovascular: B/P – 80/60 AP – 42/regular RR – 24/min O2 sat – 95% Carotid pulse felt but weak radial and femoral pulse palpated – 1+/1+
· Temperature: 94.2
· No anal sphincter tone present.
· Ecchymosis noted on right upper arm and scapular area
· Abrasions noted on face, right arm and back
· No movement, sensation or pain noted in right or left leg
· No movement, sensation or response to painful stimuli bilaterally in upper extremities.
CT scan reveals fracture in C5
All labs within normal limits
Type and crossmatch: B negative Antibody screen – negative
1. Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is ______________________________________________. What should the triage nurse do next?
2. What is the data obtained from the primary assessment?
3. What is the data that is obtained from the secondary assessment?
4. What is the diagnosis that the nurse suspects and why does it occur? Interpret and explain all the data presented and its significance.
5. What are some other causes of this diagnosis and what is your role in preventing it in other patients?
6. What are the initial nursing responsibilities?
7. What nursing assessments are essential and at what frequency should they be performed?
8. List and prioritize three nursing diagnoses for this patient.
9. What are some other collaborative problems that may occur?
10. Document your findings on the flow sheet and also document your findings using narrative format
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