KJ 26F
DX- T8 SCI
LOS- 1 day
NKA
No falls
No critical labs
PT needed to see
Rehab facility. Status post GSW
T8 comorbidity
Shift goals and Pt ducations- straight cath and info on that, focus on repositioning in bed
Path to DC- successfully cath independently (show back) and needs assistance with ADLs
Path to Death/Injury- Sepsis (not cathing properly) and pressure ulcers (skin hygiene and repositioning to
prevent pressure ulcers)
BACK-
Alert- urinary retentions, resp compromise, constipation, dvt, proper nutrition, pressureulcer
Focus- respiratory, skin, GI/GU, PO intake (leads to skin breakdown and PU)
Complications rt to DX- Pressure ulcers, bowel obstructions, resp complications, infections, risk for PE
(lack of movement)
Interventions- straight cath (prevent uti and retn) turn, pulmonary toiley, TCDB, bowel regimen (rectal
stimulation) compression stockings-
Management of Care- Per Orders VS Q8- reg hi fiber, Q8 I&O, straight cath Q4 (bladder scan) meds
reviewed and administered
Priorities- Straight Cath with Education, OOB with TCDB
Delegations- Turning
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