2. Putting It All Together
Open Resources for Nursing (Open RN) and Amy Ertwine
Client Scenario
Mr. Hernandez is a 47-year-old client admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The client sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he has significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the client has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally. Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand. Mrs. Hernandez is present at the client’s bedside and has provided additional information about the client. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure but is otherwise healthy.
The nurse notes that the client’s jaw is wired, and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.
Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.
Sample Documentation Using a Summary Note:
6/01/2024, 1615: Mr. Hernandez has impaired verbal communication due to facial fracture and inability to enunciate words around his wired jaw. He understands both verbal and written communication. Mr. Hernandez has left sided facial swelling, but no visual impairment. He has a left arm fracture but is able to move and write with his right hand. The client is supplied with communication cards and marker board. He responds appropriately with written communication and is able to signal his needs. – J. Smith, RN
