Rivier University
Division of Nursing and Health Professions
Undergraduate Nursing Education
NSG 456 Care of the Patient with Complex Health Concerns
Case Study #3: Caring for Patients with Spinal Cord Injuries
Name: (s) Kaitlyn Sarno, Chelsea Shoemaker, Jordan Parece, Chad Saint-Amant
Neehr Perfect Case: Tim Collado, https://web21.neehrperfect.com/rd/?courseActivityId=11930
DIRECTIONS
Visit the link to Tim Collado’s. Review the patient’s chart and answer the following questions.
Question #1: (40 Points total)
Given Mr. Collado’s medical diagnosis, describe how the nurse will conduct a shift assessment.
Include any of the tools the nurse will use and the expected findings. Refer to the resource in
Mr. Collado’s file called, “Early Acute Management in Adults with Spinal Cord Injury” for
assistance with completing this question. An example has been provided for you.
Body System Nursing Expected Findings
Assessment
Neuro – This is a system of Grade A=Complete: No motor or sensory
AISI tests used to define function is preserved in the sacral segments
Impairment and describe the S4-S5.
Scale extent and severity Grade B = Incomplete: Sensory but not
of a patient’s spinal motor function is preserved below the
cord injury and neurological level and includes the sacral
help determine segments S4-S5.
future rehabilitation Grade C = Incomplete: Motor function is
and recovery needs. preserved below the neurological level, and
It is ideally more than half of key muscles below the
completed within neurological level have a muscle grade less
72 hours after the than 3.
initial injury. The Grade D = Incomplete: Motor function is
patient’s grade is preserved below the neurological level, and
based on how much at least half of key muscles below the
sensation he or she neurological level have a muscle grade of 3
can feel at multiple or more.
Grade E = Normal: motor and sensory
, points on the function are normal
body, as well as
tests of motor
function.
Based on Mr.
Collado’s findings,
the result of this
test is a Grade C.
Body System Nursing Expected Findings
Assessment
Respiratory Lung sounds, Clear lung sounds, no usage of accessory
breathing pattern, muscles, regular rate and rhythm of
respirations, respirations.
oxygen saturation.
Labs: arterial blood
gases (ABGs) ,
pulse oximetry
GI Monitor for ileus High risk of paralytic ileus, ulcer,
and constipation; pancreatitis, and distension. However, it is
hypoactive BS; expected that the client will retain normal GI
abdominal functioning, as evidenced by regular bowel
distension; N/V movements, normal bowel sounds, and
absence of abdominal distension.
GU Assess bladder for No retention of urine as evidenced by output
distention; >30 mL/hour; non-cloudy or odorous urine;
retention; cloudy, no s/s of infection; no discomfort or pain. If
odorous urine, and the patient were to experience bladder
use a bladder scan retention or distension, urine output would
to see if patient is be less than 30mL/hour.
retaining urine. Patients labs show an elevated BUN and
Division of Nursing and Health Professions
Undergraduate Nursing Education
NSG 456 Care of the Patient with Complex Health Concerns
Case Study #3: Caring for Patients with Spinal Cord Injuries
Name: (s) Kaitlyn Sarno, Chelsea Shoemaker, Jordan Parece, Chad Saint-Amant
Neehr Perfect Case: Tim Collado, https://web21.neehrperfect.com/rd/?courseActivityId=11930
DIRECTIONS
Visit the link to Tim Collado’s. Review the patient’s chart and answer the following questions.
Question #1: (40 Points total)
Given Mr. Collado’s medical diagnosis, describe how the nurse will conduct a shift assessment.
Include any of the tools the nurse will use and the expected findings. Refer to the resource in
Mr. Collado’s file called, “Early Acute Management in Adults with Spinal Cord Injury” for
assistance with completing this question. An example has been provided for you.
Body System Nursing Expected Findings
Assessment
Neuro – This is a system of Grade A=Complete: No motor or sensory
AISI tests used to define function is preserved in the sacral segments
Impairment and describe the S4-S5.
Scale extent and severity Grade B = Incomplete: Sensory but not
of a patient’s spinal motor function is preserved below the
cord injury and neurological level and includes the sacral
help determine segments S4-S5.
future rehabilitation Grade C = Incomplete: Motor function is
and recovery needs. preserved below the neurological level, and
It is ideally more than half of key muscles below the
completed within neurological level have a muscle grade less
72 hours after the than 3.
initial injury. The Grade D = Incomplete: Motor function is
patient’s grade is preserved below the neurological level, and
based on how much at least half of key muscles below the
sensation he or she neurological level have a muscle grade of 3
can feel at multiple or more.
Grade E = Normal: motor and sensory
, points on the function are normal
body, as well as
tests of motor
function.
Based on Mr.
Collado’s findings,
the result of this
test is a Grade C.
Body System Nursing Expected Findings
Assessment
Respiratory Lung sounds, Clear lung sounds, no usage of accessory
breathing pattern, muscles, regular rate and rhythm of
respirations, respirations.
oxygen saturation.
Labs: arterial blood
gases (ABGs) ,
pulse oximetry
GI Monitor for ileus High risk of paralytic ileus, ulcer,
and constipation; pancreatitis, and distension. However, it is
hypoactive BS; expected that the client will retain normal GI
abdominal functioning, as evidenced by regular bowel
distension; N/V movements, normal bowel sounds, and
absence of abdominal distension.
GU Assess bladder for No retention of urine as evidenced by output
distention; >30 mL/hour; non-cloudy or odorous urine;
retention; cloudy, no s/s of infection; no discomfort or pain. If
odorous urine, and the patient were to experience bladder
use a bladder scan retention or distension, urine output would
to see if patient is be less than 30mL/hour.
retaining urine. Patients labs show an elevated BUN and
