The nurse is caring for a 38-year-old client with paraplegia…
The nurse is caring for a 38-year-old client with paraplegia who was recently transferred from critical care to a step-down unit. The client was admitted 3 days ago after a pedestrian-vehicle accident and diagnosed with a spinal cord injury and complete transection at T4.Document the client findings that require immediate follow-up: History and Physical Nurses’ Notes Orders Laboratory Results1210: Alert with symmetric facial structures and movements. Pupils equal and reactive to light and accommodation. Moves bilateral upper extremities to command and against gravity but not resistance. No movement or sensation present below mid-chest, fourth intercostal space. Tracheostomy intact with mechanical ventilation: Assist-control, rate 14, TV 750, FiO2 35%. Ecchymosis present on right chest and back. Right lower lobe chest tube in place, site clean and dry, system sealed with no leaks, serosanguineous drainage present in collection chamber. Respirations symmetric with coarse rhonchi auscultated bilaterally. Weak cough present. Sinus rhythm. Skin warm and dry. Radial pulses 3+, pedal pulses 2+, and capillary refill