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Case Study: Mr. Clooney is a 76-year-old Caucasian male who was admitted to the rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst fracture after a MVA and the site was surgically stabilized.

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Course Project Case Study: Mr. Clooney is a 76-year-old Caucasian male who was admitted to the
rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst
fracture after a MVA and the site was surgically stabilized. He is paralyzed in his lower extremities and
has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure
ulcer to his coccyx. Medical history includes asthma, substance abuse (alcohol), obesity, constipation,
prediabetes (has not progressed to type II diabetes) and tested positive for Covid-19 in November 2020
after experiencing shortness of breath and fever.
Mr. Clooney is single and lives alone in a second story apartment. His son lives three states away and he
has no relatives in the area. He is a retired construction worker, denies any religious affiliation, and
speaks English.
Orders include:
Full resuscitation
PT, OT TID, 5 days per week
Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily
Cervical collar when OOB
Transfer with sliding board per PT
Regular diet
Ensure high protein shake BID
Foley catheter to dependent drainage
Cleanse catheter site with soap and water BID
Medications Include:
Dulcolax suppository every 3 days rectally
Baclofen 5mg PO QID
Midodrine 10 mg PO at 0800, 1300 and 1800
Albuterol inhaler: 180 mcg (2 puffs) every 6 hours PRN
Metformin 500 mg PO BID
Need Nursing Diagnosis

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