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Rasmussen College Romeoville Rehabilitation for T3 Fracture Course Project Case Study

 

Course Project Case Study: Mr. Clooney is a 76-year-old Caucasian male who was admitted to the rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst fracture after a MVA and the site was surgically stabilized.  He is paralyzed in his lower extremities and has no sensation below the clavicles.  He is incontinent of bowel and bladder and has a stage 3 pressure ulcer to his coccyx.  Medical history includes asthma, substance abuse (alcohol), obesity, constipation, prediabetes (has not progressed to type II diabetes) and tested positive for Covid-19 in November 2020 after experiencing shortness of breath and fever.

Mr. Clooney is single and lives alone in a second story apartment.  His son lives three states away and he has no relatives in the area.  He is a retired construction worker, denies any religious affiliation, and speaks English.

Orders include:

Full resuscitation 

PT, OT TID, 5 days per week

Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily

Cervical collar when OOB

Transfer with sliding board per PT

Regular diet

Ensure high protein shake BID

Foley catheter to dependent drainage

Cleanse catheter site with soap and water BID 

Medications Include:

Dulcolax suppository every 3 days rectally

Baclofen 5mg PO QID

Midodrine 10 mg PO at 0800, 1300 and 1800

Albuterol inhaler: 180 mcg (2 puffs) every 6 hours PRN

Metformin 500 mg PO BID

QUESTIONS

  • a) MEDICATIONS

Choose 5 primary medications that your patient is taking and complete the information below. Upload this table into your paper to describe each medication. The information included below should directly relate to your assigned client. Do not include information that does not apply to your client specifically.

  

Drug Name Trade & generic name, dose, route &   frequency

Pharmacological & therapeutic drug class & Expected action in the body

What medical diagnosis is your patient taking this drug   for? How will it help them?

Side Effects & Adverse Reactions/ Complications/Top   drug interactions

Nursing Administration Special Instructions &   Assessments

Client Education/ Evaluation of Medication Effectiveness   (e.g. Pain Scale)

                                                                      

  • b) LABS AND DIAGNOSTIC TESTS

Choose five labs or diagnostic tests that might be ordered for your case study client.  Describe the importance of each lab/test for your specific client.  Note normal results, expected abnormal values based on your client, and what that would signify for your client.  This summary should be at least one and a half page in length.