Case: A 45-year-old white male steel worker presented to the Urgent Care Clinic three days after an accident

at work. He received a crush injury from a bucket at the end of a boom, which continued to move forwardeventually pinning him between a steel beam and the side of the bucket. An observer below saw the accident, stopped the boom and brought him to ground level. He was unconscious at the time. Bystanders called 911 and the patient aroused spontaneously within a few minutes. Emergency department (ED) evaluation with CT of the head, neck, chest, and abdomen noted. A series of four right lateral spinous process fractures from T10 to L1 and two right rib fractures #9 and #10. The remainders of the studies were reported as normal. CBC and metabolic profile were normal and a 12-panel drug screen was negative. Physical examination: Patient ambulated into the clinic alert and oriented x3. He complained of much back pain, as well as difficulties breathing and moving. Records from the ED were obtained and reviewed. Chest X-ray noted consolidation at right base, believed to be a small pulmonary contusion. O2 saturation was 98%. The patient was advised of the findings and was given prescriptions for an antibiotic and pain medication. Pulmonary toilet discussed and cigarette cessation was encouraged. A few weeks following the initiation of physical therapy, he continued to complain of right back pain and upper left chest pain. A follow-up chest X-ray revealed a displaced left 4th rib fracture not noted on prior studies. Patient was very motivated to get well. Pain management was ongoing with Oxycontin twice daily, low dose oxycodone for breakthrough pain and Valium for sleep. Eight weeks later, the patient complained of difficulty with both physical therapy and his workhardening program. He still required an opiate at least once daily for pain control. He did not feel strong, was somewhat depressed, and was having a recurrence of right back muscle spasms. Questions 1. What is your differential diagnosis? a. Rationalize your diagnosis by providing pertinent facts about the disease b. Include other signs and symptoms not manifested by your client. c. Provide necessary diagnostic procedure and laboratory exam, treatment including medications, and nursing care plan 2. Develop the concept map for your client by following guidelines below: a. There was no right or wrong way to do the map. b. The map should be what you felt was useful information c. Identify relevant concepts in the material. From this identification a hierarchical structure is developed selecting appropriate linkages to from valid propositions. d. The client is the center of the map

e. Include somewhere on the map: Risk factors (Violet) Pathophysiology (PINK) Medical diagnosis (RED) Assessment data (signs, symptoms, test results, pertinent history) GREEN Nursing diagnoses (Yellow) Goals and outcome criteria BLUE Nursing interventions ORANGE Evaluation BLACK f. Show the connections between the parts of the nursing process by drawing connecting lines