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Physician Orders (Medications) Scheduled Meds: Medication Dose Route Frequency Time to be administered

See Attached Drug Cards. PRN Meds: Medication See Attached Drug Cards Dose Route Frequency

ALL OTHER PERTINENT/CURRENT PHYSICIAN ORDERS: (Including diet, IV fluids, activity orders, and others as appropriate to this patient).

Diet: Started as a normal diet on day one, then changed to a diabetic diet on day two (carbohydrates and sugars were closely monitored). IV Fluids: My patient did not have an IV

Orders: My patient went to OP and PT every day for one hour each. He was also termed an assist x2 so whenever he needed to leave his bed, 2 people had to assists in his movements. No labs were ordered for my patient. The only other thing monitored were his blood glucose levels, which were ordered at 7 AM, 11 AM, 4 PM, and 9 PM


See database for lab values. The only diagnostic procedure done was an MRI, which showed grade 1 anterior listhesis of the C3 on C4 and posterior osteophyte complex causing severe stenosis to 5mm. Doppler to extremities was negative. His pre-operative diagnosis was cervical stenosis, myelopathy, quadriplegia, cent cord injury post fall. On August 29, 2012 a posterior cervical laminectomy, medical factectomy, with forammotomy mass scew rod fusion was done (C2-C3, C3-C4, C4-C5, C5-C6, C6-C7, C7-T1).

SOAP NOTE 1. S: See attached complete Subjective column in the database and also the Nursing Care Plan.
2. O: See attached complete Objective column in the database and also the Nursing Care

Plan. 3. A: 4. P:


Student Name: Kylie Casey Date: 9/3/12- 9/6/12

ASSESSEMENTS (Subjective/Objective Data pertinent to this nursing diagnosis) Subjective:

NURSING DIAGNOSIS NANDA diagnosis? Related factors noted? Evidence if an actual problem?

NURSING INTERVENTIONS Note Frequency. (Consider assessments, treatments, & teachings pertinent to diagnosis)

EVIDENCE SUPPORTING PRACTICE (Rationale) (Cite source: Author & Page #) List full reference separately.

IMPLEMENTATION Explain how interventions were met or explain why they were not.

EVALUATION State outcome achievement in behavioral terms. Note: Continue , Change (specify), Discontinue POC

Impaired physical mobility related to Patient states: I I neuromuscular cannot feel my hands a lot of the impairment as evidence time. by patients statement: I cannot feel my hands Patients states a 6 level of pain out of a a lot of the time. 10 scale.

1. Continually assess motor function (as spinal shock/edema resolves) by requesting patient to perform certain actions, e.g., shrug shoulders, spread fingers, squeeze/release examiners hands.

1. Evaluates status of individual situation (motor-sensory impairment may be mixed and/or not clear) for a specific level of injury, affecting type and choice of interventions.

1. Neurological checks

1. Goal met: patients neurological were performed every day checks were successfully complete by the collaborative care once a day by a member of the team. health care team.
2. PT and OT therapy were 2. Goat met: Patient successfully schedule for one hour a day participated actively in OT and PT each, every day. therapy for one hour a day each.

Objective: General body weakness. Tremors in the right hand. Unsteady gait. Inability to perform gross fine motor skills, such as using silverware to eat.

OUTCOME STATEMENTS Measurable? Realistic? Time element noted? Pertinent to diagnosis?

Increase strength of unaffected/compensator y body part (hands) by being able to carry out normal activities of daily living (for the patient) by time of discharge (9/18/12).

2. Perform/assist with full ROM 2. Enhances circulation, exercises on all extremities and joints,restores/maintains muscle tone using slow, smooth movements. and joint mobility, and prevents 3. PT and OT times were 3. Goal met: Patient actively Hyperextend hips periodically. disuse contractures and muscle scheduled with breaks in participated in his daily schedule between them. Activites and ensured there were periods of atrophy. and other forms of care rest. were also spread out on the 3. Plan activities to provide 3. Prevents fatigue, allowing patients daily schedule in 4. Goal met: Weight bearing uninterrupted rest periods. Encourage opportunity for maximal order for the patient to have exercises were perfomed in both involvement within individual efforts/participation by patient. rest time. OT and PT therapy daily. tolerance/ability. 4. This intervention was 5. Goal met: Patient worked with 4. Early weight bearing reduces carried out though PT and health care staff to develop a plan 4. Prepare for weight-bearing osteoporotic changes in long activities, e.g, use of tilt table for OT sessions daily. of care that met their indivudal bones and reduces incidence of upright position, needs. strengthening/conditioning exercises urinary infections and kidney 5. The collaborative health stones. care team met once a week for unaffected body parts. to discuss the patients progress and what they plan 5. Consult with physical/occupational 5. Helpful in planning and implementing individualized to do next to further his therapists/ exercise program and care. rehabilitation team. identifying/developing assistive devices to maintain function, enhance mobility and independence.