Case Study: Joe, eighteen years old and

Case Study: Joe, eighteen years old and unmarried, sustained a severe spinal cord injury in a motor vehicle accident. His arms and legs were paralyzed. He initially required mechanical ventilation and, later a tracheostomy. Three months after his injury, Joe was transferred to a spinal cord unit several states away for his rehabilitative care. Joe was eventually able to be weaned from the ventilator, but his pulmonary status remained shaky. He had an ineffective cough and required frequent assistance and suctioning to manage his secretions. Goals for his rehabilitation included educating him about his body so he could direct his care (range motion, bowel and bladder care transfers from bed into the wheelchair, medications, and the like). It was felt that Joe could eventually use mouth-controlled computer technology to propel his wheelchair, use the phone, monitor the TV, switch lights off and on, and operate a computer. Before the accident, Joe worked as a supermarket packing clerk and lived with his mother and stepfather. He had finished tenth grade and earned a GED. He was described by his psychologist during his rehabilitation course as being frightened, anxious, and emotionally fragile, though not depressed. He met the staff’s attempts to care for him with extreme opposition, often refusing therapies, medications, and treatments for the pressure sores that he had developed. He demanded to be allowed to smoke, despite his fragile respiratory status. One of the goals for Joe’s rehabilitation course was to remove the tracheostomy, if possible. With time and special respiratory management, his Clearance of secretions improved. A “button” (or space holder for a tracheostomy) was eventually placed— the final stage before complete de-cannulation. At this point, Joe had to rely on others only for help with coughing and oral suctioning to manage his seniors. If he cannot conduct his pulmonary toilet adequately, the tracheostomy tube could easily be replaced at the bedside to allow for more aggressive suctioning. Several nights after the button placement, the resident on call was summoned to evaluate Joe for respiratory distress. His respiratory rate had increased, and his blood gas indicated mild hypoxemia. He was having a great deal of difficulty managing his secretions, despite one-on-one attention from the staff for cough assistance and oral sectioning. The resident on call felt that the tracheostomy tube should be replaced immediately, but J e refused. “I’d rather die than have that replaced,” he said. The resident explained to him that it would be a temporary measure to ensure the clearance of secretions and appropriate oxygenation. Joe remained adamant. Now what? Patient 1 Initials:_________ Age:________ Rm #_________ MOST ____________ Data – Objective/Subjective Concept Map Assessment Data: Highlight Salient Points (Review each body system and place detail areas under each section as needed) Nero Sensory Circulation Oxygenation Elimination Metabolism Mobility Cellular Dynamics Protection Reproduction List in o List an order of priority (the most important/imminent), two nursing diagnosis nanda based. Give rationale for the priorities you have selected. Nursing Focus of Care / Nursing Diagnosis Rationale for Priority SCIENCE HEALTH SCIENCE NURSING NURSING 422

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