NMNC 4310 - Mobility

hyperextension injury

spine extended too far forward anteriorly

what is included in primary prevention for spinal cord injuries?

sports & outdoors education safety equipment

How do you care for pt c botulism?

- botulinum antitoxin - abx - may req vent - supportive care - nutrition - skin integrity

how do you tx pt w autonomic dysreflexia?

- check clothing/sheets, toenails + soles of feet - sit pt up to lower BP and give you time before veins are damaged - check BP Q5min - ensure good bowel + bladder care - reduce stem when giving enemas - med alert bracelet if previous event

what is a partial cord transection?

- cord isn't completely there may still be some retained sensory-motor function - Hx of injury - stabbing, GSW (gunshot wound) - changes in sensation - improving/deteriorating - movement crosses over and goes to brain, sensation goes directly to brain - (EX) central cord, anterior cord, posterior cord, brown sequard

How does a fractured hip present?

- hip pain - leg shortened - externally rotated

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

2. Assess for a full bladder.

Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion

3. Ineffective Airway Clearance

Which complication would the nurse monitor for in a client on strict bed rest for 3 days? Select all that apply. Atelectasis Hypotension Constipation Pressure injuries Urinary tract infection

Atelectasis

A patient with a femur fracture presents with SOB and petechiae on the face, the nurse should be concerned for A) DVT B) Fat embolism C) PE D) Stroke

B) Fat embolism

Neurogenic (vasogenic) shock

Caused by unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation.

When giving discharge instructions for cast care the nurse includes: A) keep the arm hanging down to improve circulation B) use a coat hanger to itch in the cast C) use a hair drier to help dry it after it has got wet. D) Keep the hand at the level of the heart

D) Keep the hand at the level of the heart

An expected outcome of cast application that the nurse evaluates is: A) Skin irritation at the cast edges B) Decreased cap refill C) Tingling and numbness distal to the cast D) Slight edema, soreness, and limitation of range of motion

D) Slight edema, soreness, and limitation of range of motion

The nurse is providing care to a client. Which nursing action has the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process? Removing the cervical spine collar Monitoring for autonomic dysreflexia Implementing the logrolling technique Administering the prescribed pain medication

Implementing the logrolling technique

flexion injury

Forward dislocation Ruptured posterior ligaments

T5 spinal nerve function

GI motility

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? Hypertension and bradycardia Flaccid paralysis and numbness Absence of sweating and pyrexia Escalating tachycardia and shock

Hypertension and bradycardia

The nurse finds the client on the floor, crying for help, with signs of a hip fracture. Which action would the nurse take first? Administer pain medication. Place the affected extremity in traction. Immobilize the affected extremity. Notify the primary health care provider on call.

Immobilize the affected extremity

A 9-year-old child has a fractured tibia, and a full leg cast is applied. Which assessment findings would the nurse immediately report to the health care provider? Select all that apply. Increased urine output Inability to move the toes Pedal pulse of 90 beats per minute Tingling sensation in the foot Fiberglass cast that is damp after 4 hours

Inability to move the toes Tingling sensation in the foot Fiberglass cast that is damp after 4 hours

Which item in the plan of care for a client with paraplegia would the nurse question? Change the client's bed position hourly. Use supportive devices to maintain body alignment. Instruct the client to do active leg exercises. Perform passive leg exercises several times daily.

Instruct the client to do active leg exercises.

Spinal shock

Loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. Last days to weeks.

Muscle atrophy

Loss of muscle tone

Gait

Manner or style of walking

Range of motion

Maximum amount of movement available at a joint

Paraplegia

Paralysis and loss of sensation in the legs

Tetraplegia / Quadriplegia

Paralysis in all 4 extremities

Which intervention would the nurse perform first to manage the condition of a client with autonomic dysreflexia? Cover the client with blanket. Place the client in a sitting position. Assess the client's urinary retention. Administer alpha blockers to the client.

Place the client in a sitting position.

Which nursing interventions would the nurse avoid when providing care for a client with a fractured extremity? Keeping the client warm and dry Removing the client's shoes or boots immediately Immobilizing the affected extremity Allowing the client to lie in supine position

Removing the client's shoes or boots immediately

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest

Tachycardia and petechiae over the chest

Activity tolerance

Type and amount of exercise that a person is able to perform without undue exertion or injury

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following actions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication

c. check the client's urinary catheter for blockage

T6 and above spinal nerve function

cardiac - injury will cause HoTN & bradycardia

What is included in the diagnosis & care for mobility issues r/t neurological fxn?

diagnosis - genetics, MRI, lumber puncture, muscle biopsy, blood, often a diagnosis of exception tx - symptom control (steroids), comfort measures (pain meds), meds per diagnosis nursing care - muscle weakness, safety, skin integrity, airway, breathing, mental health, often incurable

C4 spinal nerve function

diaphragm - pt w injury can't breathe

What is halo traction?

immobilizes cervical spine when a cervical fracture occurs

flexion-rotation injury

may result in fracture or dislocation, tearing or shearing of cord

how do you stabilize the spine after injury?

non-operative - halo traction, collars, clamshell braces TLSO, spinal board, log roll, assess sensation operative - pins, rods, plates

How do you initially treat a fractured hip?

pain meds check distal pulses - before & after moving traction - reduces muscle spasm

what are some hip fracture post op complications?

pneumonia skin breakdown muscle wasting bone demineralization

How do you care for pt c Bells Palsy?

- NSAIDs - antiviral - 6mos-yr to recover - oral & eye care

What is Brown-Sequard syndrome?

- side of lesion - hypertonic paralysis, spastic paralysis & loss of vibration & proprioception (position sense) & fine touch - opposite side - loss of pain & temp sensation - image to half cord - often penetrating injury - Tx symptoms - depends on level, supportive care, rehab

A client with a history of spinal cord injury (SCI) reports a severe headache and blurred vision. Upon assessment, the nurse notes the following: hypertension, bradycardia, and a flushed face. Which intervention should the nurse implement first? A. Apply compression stockings B. Lower the head of the bed C. Empty the client's bladder D. Increase the IV flow rate

C. Empty the client's bladder

what are examples of neurological mobility issues?

Multiple sclerosis - caused by immune response, blurred/double vision Amyotrophic lateral sclerosis - inherited, fine motor skills

Hemiplegia

One-sided paralysis

what is SCIWORA?

spinal cord injury without radiographic abnormality - numbness, tingling, paralysis - xrays + CT normal - tx - immobilize, steroids, pain meds, symptom cntrl, use a collar

T1-L2 spinal nerve function

urinary - injured pt will have urinary issues

what is included in post op hip fracture care?

- VS - wound monitoring - abduction pillow - prevents hip rotation - IS - over bed trapeze - watch elbows for skin breakdown (they use them to scooch up in bed)

what is included in secondary prevention for spinal cord injuries?

- deep breathing - PT / OT - mobility - stabilize - if in doubt immobilize - DVT prophylaxis - VS - pain meds - AD prevention - skin integrity

spinal cord injuries

- fix orthopedic issues through surgery spinal cord - no transmission of stimuli to brain - no "ouch" - no transmission of stimuli to muscle - no movement

What is spinal shock?

- lack of sympathetic nerve response (higher up = more problems) - HoTN - bradycardia - temp dysreg - once spinal shock is fixed, it doesn't return - can take wks - physiological reaction to depression of cord below the SCI level - loss of sensorimotor function & flaccid paralysis

what is autonomic dysreflexia?

- life-threatening emergency in T6 or higher spinal cord injury patients that causes a hypertensive emergency - occurs any time AFTER spinal shock has resolved - S/S - headache, diaphoresis, nausea, nasal congestion, bradycardia

how does skeletal (pins) traction work?

- long term traction - if pt is not an anesthesia candidate (age, comorbidities, renal/liver) - can be wks-mos - reduces muscle spasm - reduces pain & tissue damage

What is botulism?

- nerve paralysis due to toxin buildup - toxin blocks release of acetylcholine in synapse - food poisoning - blood in stool/vomit - giving children honey

compression fracture

- occurs when the bone is pressed together (compressed) on itself - crushed fragments

what are some surgical procedures for hip fracture repair?

- open reduction procedures - anesthesia required (open = cut open) - pins & plates - hip replacement - rehab, hip joint deterioration, PT/OT

how does Buck's (skin) traction work?

- pulls bone - applies tension to reduce muscle spasm & assists in realigning bones - tape applied to skin up to knee - weights pull leg & apply tension to hip + femur - reduced muscle spasm - reduced pain & trauma to surrounding tissue - skin care & keep it swinging

how do you get a spinal cord pt ready to go home?

- rehab - strength building exercise - I&O - nutrition - rf infxn - lung (pneumonia) & kidneys (UTI) - mobility adjuncts - mental health - family support

what are some risks with skeletal traction?

- skin breakdown - pin infxn - muscle wasting r/t immobility - lengthy recovery if at all - bone demineralization

What is Bell's palsy?

- unknown cause - maybe viral? - Ipsilateral facial paralysis w inability to close affected eye - acute onset over 1-2 days, progressively worsening weakness over 3 weeks, recovery in 6 months - dx - CT & MRI (mostly to rule out other conditions) - Unilateral facial nerve paralysis - Hyperacusis (paralyzed stapedius muscle) - differentiated from stroke bc BP only affects face

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

2. assessing the patient's skin integrity 4. administering pain medication 5. providing passive range of motion

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

2. spinal shock

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

3. elevated blood pressure

The team is assessing a patient's right leg for neurovascular problems. What assessment finding(s) shows a neurovascular problem? Select all that apply. A. 1 + pedal pulse B. 5/5 motor strength C. Numbness and tingling D. Pink and warm skin E. Cap refill is 2 seconds

A. 1 + pedal pulse C. Numbness and tingling

The nurse is preparing a teaching plan for a patient who is being discharged following a total hip replacement. The nurse would include which part of the following content as a part of the teaching plan? Select all that apply A. Avoid low, cushioned chairs B. Use a device that raises toilet seat C. Avoid bending greater than 90 degrees D. Turn at the waist to reach objects E. Do not cross the legs

A. Avoid low, cushioned chairs B. Use a device that raises toilet seat C. Avoid bending greater than 90 degrees E. Do not cross the legs

A patient with a SCI has asked to be turned to their side. What precautions must be implemented to prevent injury? (Select all that apply) A. Logroll the patient when moving B. Keep the patient's body in correct alignment at all times C. Administer morphine prior to moving D. Provide a bedpan prior to moving

A. Logroll the patient when moving B. Keep the patient's body in correct alignment at all times

The team receives a call from the lab that needs to be taken. What patient care can be delegated to the patient tech for a SCI patient? (Select all that apply) A. Obtain a blood pressure B. Assess the IV site C. Do initial teaching for incentive spirometer D. Turn the patient independently E. Chart fluid intake

A. Obtain a blood pressure E. Chart fluid intake

When teaching cast care, the nurse instructs the client to: A) Blow dry the wet cast with a hair drier B) Report changes in sensation or mobility to the area C) Use only soft objects to slide down the cast for scratching D) Cut away the edges of the cast if the skin becomes irritated

B) Report changes in sensation or mobility to the area

During assessment, the patient reports muscle spasms in lower legs. Which medication will be given to help control spasms? A. Bacitracin B. Baclofen C. Colace D. Pepcid

B. Baclofen

On assessment, the patient has 2+ pedal pulses; is able to move right toes; denies numbness and tingling; cap refill is 1 second; pain is 5/10 in right leg; reports "my splint is tighter". What are nonpharmacological measures that can reduce pain for this patient? (Select all that apply) A. Apply sequential compression devices to affected extremity B. Ice affected extremity C. Massage the affected extremity D. Help the patient with knee range of motion E. Elevate the affected extremity

B. Ice affected extremity E. Elevate the affected extremity

Assessment findings show: SpO2 is 89%, RR 24, crackle lung sounds. What is the priority nurse intervention? A. Turn the patient to the left laying position B. Suction the patient C. Increase intravenous fluid intake D. Have the patient use the incentive spirometer

B. Suction the patient

While in Buck's extension traction, the client may be positioned: A) On the back, with the knees flexed 45 degrees B) On the back, with the buttocks slightly elevated off the bed C) On the back, turning to the unaffected side for 10- to 15-minute periods D) On the back, with the bed tilted toward the side that is opposite the traction

C) On the back, turning to the unaffected side for 10- to 15-minute periods

Your patient is post operative SCFE (Slipped epiphyseal head). The patient develops a fever on day 3. The wound is red and draining. The nurses priority concerned should be for: A) Wound infection B) Growth deficit on that leg C) Osteomyelitis D) The other leg also being impaired

C) Osteomyelitis

When assessing a patient with a spinal cord injury, the team recognizes that the most priority intervention is to? A. Maintain body alignment B. Pain control C. Maintain an airway D. Therapeutic communication

C. Maintain an airway

A patient complains of tingling and numbness in his right leg following application of a long leg cast. The patient's discomfort is most likely the result of: A. Reduced venous return B. Bone healing C. Arterial insufficiency D. Nerve compression

D. Nerve compression

Hemiparesis

One-sided weakness

For a client with a fractured femur, a nurse is alert to the possibility of a fat embolus. The nurse specifically watches for: Bradypnea Restlessness Bradycardia Hypertension

Restlessness

How do you treat spine injury?

Stabilize Hx - ID mecahnism of injury, baseline sensation & changes, VS ABC's - oxygen Meds - antiemetics, pain meds, steroids DVT prophylaxis

What is cauda equina syndrome?

cauda equina - sack of nerve roots (nerves that leave the spinal cord between spaces in the bones of the spine to connect to other parts of the body) at the lower end of the spinal cord - injury causes inability to move & feel sensation in bowel + bladder

what is included in tertiary prevention for spinal cord injuries?

community education awareness

C1-3 spinal nerve function

cough - pt w injury will have apnea & no cough

what should you include in pt ed for hip fracture prevention? post op?

prevention - osteoporosis - weight-bearing exercise - home safety evaluation - don't smoke - eat well (calcium + vitamin D) - fluids - prevent kidney stones post op - mobility - safety - raise toilet 90° - don't bend past 90°