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M.R. - 21 y.o. Male Full Code - Coggle Diagram

- - - - Diagnosis: Torn ACL, left fibula fracture, dislocation of left ankle joint, right tibial plateau fracture, fracture of manubrium, pelvic ring injury, TBI, acute blood loss anemia,
        
        Pathophysiology: Obstruction to blood supply, swelling of brain, fluid and electrolyte imbalances, inflammation and prostaglandin response, and movement impaired. Additionally, at risk for seizures, blood clots, and stroke.
        
        Assess for worsening s/s
        
        Mental status change
        
        Admin levetiracetam, magnesium oxide, propranolol
        
        Decrease stimuli
        
        Ensure pt keeps neck brace in place
        
        Provide continuing education on need for brace
        
        GCA: 15 (mild head injury
        
        Critical VS changes
        
        Pt exhibiting tachypnea occasionally and diminished and shallow breath sounds
        
        Continue to monitor/ inform provider
        
        Monitor labs
        
        Decreased HCT, HBG, creatinine
        
        Decreased kidney function & anemia d/t blood loss
        
        1 more item...
        
        Increased WBC
        
        Likely d/t trauma continue to monitor for s/s of infection/sepsis
        
        1 more item...
        
        Assessment for DVT / embolism
        
        Encourage pt to get OOB and work w/ PT and OT
        
        Admin enoxaparin
        
        Assess for bowel obstruction
        
        Admin Senna and Miralax
        
        Encourage pt to get OOB and work w/ PT and OT
        
        Assess Pain
        
        9/10 pain
        
        oxycodone administered
        
        Open reduction fixation of left ankle joint and fibula fracture.
        
        Closed treatment of rt tibial plateau, pelvic ring, rt ACL.
- - - - Nursing interventions
        
        Collaborate w/ PT and OT
        
        Encourage pt
        
        Understand limitations to recovery and create care plan around
        
        Help pt create and understand pt goals to recovery
  - - - May be difficult to concentrate and keep both eyes open until eye heals
    - - May impact attention and ability to concentrate on stimuli
  - - - Potential for mental health decline
        
        Assess mental status and supply patient w/ pt specific resources
- - - - Pt goals need to be set and continual monitoring and structured setting
  - - - Continue to evaluate support