matt a 54 year old roofer just fell 12 meters from a building under construction intially he struck the ground with his feet than fell on his left side. consious and alert at the same he complaint of severe back and lower leg pain. his vital signs bp 140/88 mmhg, hr 112 bpm respiratory rate 28 bpm sao2 96 on room air. tempreature 36.7 his glassgow scale `15,
matt a 54 year old roofer just fell 12 meters from a building under construction intially he struck the ground with his feet than fell on his left side. consious and alert at the same he complaint of severe back and lower leg pain.
his vital signs bp 140/88 mmhg, hr 112 bpm respiratory rate 28 bpm
sao2 96 on room air. tempreature 36.7 his glassgow scale `15,
paramedics administerated oxygen at flow rate of 15 litre per minute via non rebreather mask and apply a cervical collar and back board to immobalise his neck and spine. they also place a 16 gauge perpheral itravenous canula in his left forearm and begin an infusion of 0.9 sodium chloride solution.
when matt is rought into emergency deprartment, he can speak clearly prvide an account of the accident.
identify the 4 minimum nursing assessment with rationale that should be provided in the first hour upon recieving matt from paramedics.
Nursing assessments :- the following assessment should be done by the nurse.
1. Check the extrimities and back for any open injury or fracture . Use logrolling technique .
Rationale :- patient has history of fall from height so the nurse have to check for any open wound.
Logrolling technique should be used because we suspect spinal cord injury.
In case of spinal cord injury turning and twisting can cause further increase in severity of the disease.
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