Exam 3
What is key to the recovery of a pt with a SCI?
Early treatment is key to recovery. The extent of the injury may take several days to weeks to fully be realized. Be honest and patient. It is very common to not have movement or feelings for days to weeks after an injury has been sustained
What is a spinal cord injury?
Result of concussion, contusion, laceration, compression, or complete transaction of the cord
Respiratory therapy in SCI
administer oxygen with endotracheal tube, be very careful with extension of the neck make sure c-collar is in place
Primary assessments in the ED
airway/cervical spine: stabilize the head and neck but get pt to safety first. If pt falls, put them on back board and get them into bed. Do NOT leave pt on floor and wait until x-ray comes. Establish an airway breathing circulation: pulse, BP, cap refill disability: obvious disability from current or previous event?
What does the neurologic level refer to in a SCI?
refers to the lowest level at which sensory and motor functions are normal -below the level of injury is total sensory and motor paralysis
Therapeutic communication examples
"Okay, that's fine. I'm here if you need me. Don't be afraid to find me when you're ready." "Talking won't change what happened. Talking will allow you to learn how to cope." "Please tell me more about challenges you have faced since being home." "I'm sorry for your losses. It is normal to experience flashbacks and nightmares after what you've been through. What bothers you most about how you've been feeling?" "You are right a lot of women in the service do face unique challenges when they return home. Have you had any other problems, such as trouble falling or staying asleep, irritability, or anger?" "Given your experiences and your problems with sleeping, nightmares and irritability, you may be suffering from PTSD, which is common among veterans; getting help early can improve recovery, how would you feel about that?" "Yeah, its really common for terming veteran to feel emotionally numb and unable to connect. If you have PTSD you should know it is manageable with treatment from a trained mental health professional. I can help you find a doctor." "That's okay. There are a lot fo resources I can help you get connected with since people struggle with mental health problems throughout life." "I have contact information for veteran's services, websites about PTSD, and specialized health professionals. Let's look this over and decide what you think is best" "Let's plan on you calling the clinic within the next 24 hrs to schedule an appointment. We can also schedule a follow up appointment for next month to check in, if you'd like."
Describe autonomic dysreflexia
-acute emergency -occurs after spinal shock has resolved and may occur years after injury or lesions above T6 -stimuli may be below the level of injury; include distended bladder, distention or contraction of visceral organs --> constipation, or stimulation of the skin --> ingrown toenails) Prevention is key! Make sure bladder isn't full via bladder scan and make sure Foley catheter is patient and doesn't need to be emptied -S/sx: severe pounding headache, sudden increase in BP that can cause rupture of a cerebral blood vessel, profuse diaphoresis, nausea, nasal congestion, and bradycardia
Avoidance in pts with PTSD
-attempt to avoid or dull the memory of the event -may feel emotionally numb and isolate from others ex: avoid going near places where the trauma occurred, avoid sights sounds smells or people that reminders of the traumatic event, feelings of emotional isolation from others, and anhedonia
Describe neurogenic shock
-life threatening -occurs within 30 minutes of injury and can last up to 6 weeks -T6 and above -caused by the loss of function of the autonomic nervous system -decreased BP, HR, and cardiac output -venous pooling -Poikilothermia: paralyzed portions of the body do not perspire
Describe Spinal Shock
-not life threatening -after a spinal trauma, the spinal cord swells. The nervous system is unable to transmit signals so there is a sudden depression of reflex activity below the level of spinal injury -can last 4 to 6 weeks -s/sx: muscular flaccidity, lack of sensation, absent reflexes -think autonomic dysreflexia
Skeletal reduction in SCI
-used to restore to normal position Gardner-wells tongs (no drilling) Crutchfield or Vinci tongs (drilling) - if pins in place, keep them clean. Do not tighten or replace them. If one comes out, call the physician Traction - used to achieve alignment and gradually increased to keep neck in neutral position; weights hang freely off bed. they should NOT be sitting on the floor Halo device or vest
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the player's vital signs, if possible. C)Perform a rapid assessment of the player's range of motion. D)Assess the player's reflexes.
A) Ensure that the player is not moved. -at the scene of the injury, the pt must be immobilized on a back board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.
B) Notify the neurosurgeon of the occurrence. If one of the pins becomes detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon.
What are the 5 interventions?
ECG monitor Pulse ox Urinary Catheter NG tube Lab studies
How often should you assess the pin insertion site?
Every 8 hours for inflammation and infection; loose cover dressings should be applied to pin sites
What secondary assessments will you perform in the ED?
Exposure/environmental control - methampethatime fumes will affect lung status Vital signs/5 interventions/Family presence - 1 to 2 members can stay to calm pt down and see transparent care Comfort measures History and head-to-toe exam Inspect posterior surfaces!!
Glasgow Coma Scale
GCS 3 is the worst GCS 15 is the best alert, verbal, pain, unresponsive
What medication will you give to a patient experiencing autonomic dysreflexia
Ganglionic blocking agent - Hydralazine hydrochloride IV vasodilator to relax muscles and open blood vessels onset: 5 to 20 min peak: 15 to 30 min duration: 2 to 6 hours vasodilator or Nifedipine/nitrates - fast acting but the pt has to be able to chew them
How do you evaluate the progress of a pt with PTSD
Getting better is different for everybody Evaluation depends on symptomology the pt was displaying Ex: sleeping better, partaking in more group activities
What is PTSD?
Happens when people go through traumatic incidents in their life time and a stress-related reaction occurs ex: combat exposure, child sexual or physical abuse, terrorist attack, sexual/physical assault, serious accident, natural disaster common reactions: fear, sadness, guilt, anger, and sleep problems. These reactions don't go away over time and disrupt their life
Airway interventions
Head-tilt/chin lift instead of jaw thrust because it can cause damage rapid intubation
Pharmacological therapies in SCI
High doses of IV Corticosteroids or methylprednisolone sodium succinate (Solumedrol) in the first 24-48 hrs -can cause variety of complications such as infection, respiratory compromise, GI hemorrhage, and death Combination of antibiotics, anti diabetic (Glyburide), and anti-inflammatories
What are some concerns you have for a pt with a SCI?
Ineffective breathing pattern and airway clearance related to weakness of intercostal muscles Impaired physical mobility Disturbed sensory perception Risk for impaired skin integrity Impaired urinary elimination Constipation Acute pain
Circulatory Interventions
Insert 2 large bore IVs in upper extremities unless contraindication - for possible blood transfusions IVF resuscitation - 500 or 1,000 ml/hr type & screen blood PASG - pneumatic anti-shock garment maintains circulation and is only used in ED on victims of pelvic fracture
What is the RN's role in dealing with death in the ED?
It is NOT the nurse's responsibility to call the family. If the family asks if the pt is okay...say "there as been an accident and it is important that you come to the hospital immediately
Nursing interventions to promote mobility
Maintain proper body alignment Turn only if spine is stable and you have an order Monitor BP with position changes PROM 4 times/day Use neck brace or collar as prescribed when patient is mobile Move gradually to erect position Support with lots of pillows to keep comfortable - put pillow in between legs when lying on side Tight bedsheets and draw sheets with no creases - especially shoulder blade area
Nursing interventions to promote breathing and airway clearance
Monitor pulse ox, ABG, and lung sounds Suction as necessary - 3 passes with less than 10 second each, sterile, avoid stimulating vagus nerve to produce bradycardia leading to cardiac arrest, look at HR Breathing exercises - IS 10 times/hr correctly, turn cough and deep breathe if there is an order Assisted coughing Humidification and hydration
What to assess in a pt with PTSD
Most important question to ask - have they ever served and are they suicidal Most common symptoms seen are nightmares/night terrors, while fewer people experience flashbacks
How to provide comfort measures in ED?
Pain management via analgesia or alternative measures Verbal reassurance Establish trusting relationship- nothing can sub for kinds works and touch Prayer, mindfulness, and meditation
Nursing interventions for autonomic dysreflexia
Place pt in seated position to lower BP Rapid assessment to identify and eliminate cause Empty the bladder using a urinary catheter, irrigate or change indwelling catheter Examine rectum for fecal mass Examine skin Examine for any other stimulus Label chart or medical record that pt is at risk for autonomic dysreflexia Instruct patient in prevention and management
Mindfulness
Practicing mindfulness regularly can help with anxiety The idea of centering yourself, here and now, without judgement
Describe primary and secondary spinal cord injuries
Primary injury - result of the initial trauma; typically permanent Secondary injury - resulting from SCI and include edema + hemorrhage
What is the responsibility of the triage nurse?
Prioritization about what needs to be done on each pt
Emergency management of a pt with a SCI
Rapid assessment Immobilize pt Extricate from unsafe areas Cervical collar and backboard to stabilize during transport -improper handling can cause further damage
What are some symptoms of PTSD?
Re-experiencing: nightmares/night terrors, flashbacks avoiding situations: people, places, or things that bring back memories of the event negative changes: in beliefs and feelings, trouble experiencing emotions, thinks no-one can be trusted, feel guilt and shame hyper-arousal: jittery and on the lookout for danger, suddenly becoming angry or irritable
What is cognitive processing therapy?
Reframing the way you think of something so subsequent actions are changed gives you skills to handle distressing thoughts and understand what you went through and how it changed you Learning your symptoms and how treatment can help Become aware of thoughts/feelings Learn skills to challenge thoughts Understand the changes Group therapy works very well with PTSD pts
Examples of medications that are used in pts with PTSD
SSRIs: citalopram, escitalopram, fluvoxamine, paroxetine, sertraline, fluoxetine Can take up to 4 to 6 weeks to fully kick in but can start in 2 to 4 weeks PTSD is considering an anxiety disorder so they might receive Buspirone (BuSpar) - anti anxiety med that can be used long term. Normal dosage of 5 mg. It is not addictive and the pt will feel less anxious in 7 to 10 days
What is the major concern in pts with PTSD?
Safety - ask about suicide
What is the major cause of death in pts with spinal cord injuries?
Septiciemia Pulmonary emboli Pneumonia
True or false. Never massage the calves or things because of the danger of dislodging an undetected DVT.
TRUE
Other Interventions for SCI pts
Temporary indwelling, intermittent, or external catheter NG tube High-calorie, high-protein, high fiber diet Bowel program: stool softeners, disimpaction, enemas Traction pin care - keep clean and call physician if one comes out
What are the available treatments for pts who suffer from PTSD?
The combination of psychotherapy/counseling with medication will produce the most results! -psychotherapy: cognitive behavioral therapy such as cognitive processing therapy and prolonged exposure therapy, eye movement desensitization and reprocessing -medication: SSRIs The most important thing is to let the pt and their family know that there are options out there
Securing the ED environment
Things with locks need to be locked (IV carts, med carts, sharp boxes, etc.) without the key in the keyhole
How do you triage in the ED?
Threats to life, vision, or limbs should be treated first Questionable airway always gets seen first - swollen face, broken jaw, bruising on neck Gunshot wounds take precedent - try to preserve the evidence Non-urgent: broken bones, car wreck with no life-threatening injuries
Interventions to maintain skin integrity
Turn q2h if ordered PROM positioning mepilex on boney provinces
Exposure/environmental control
Undress pt - cut off clothing if necessary but protect the evidence remove jewelry and prosthesis - cut off rings if fingers are swollen but do it in the presence of somebody, artificial limb is removed and given to family to take home or keep in the room
What are risk factors for spinal cord injuries?
Young age Male gender Alcohol and drug use
A pt with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? a. absence of reflexes along with flaccid extremities b. positive bcbinksins reflex along with spastic extremities c. hyperreflexia along with spastic extremities d. spasticity of all 4 extremities
a. absence of reflexes along with flaccid extremities
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? a. check the pt's indwelling urinary catheter for kinks to ensure patency b. lower the HOB to improve perfusion c. administer analgesia d. reassure the pt that headaches are expected after spinal cord injuries
a. check the pt's indwelling urinary catheter for kinks to ensure patency
A patient has been brought to the ED with multiple trauma after a MVA. After immediate threats to life have been addressed, the nurse and trauma team should take what action? a. perform a rapid physical assessment b. imitate health education c. perform diagnostic imaging d. establish the circumstances of the accident
a. perform a rapid physical assessment -done to identify injuries and priorities of treatment, then diagnostic imaging would take place
A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patients care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses? a. risk for impaired skin integrity b. risk for falls c. risk for imbalanced fluid volume d. risk for aspiration
a. risk for impaired skin integrity
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? a. the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel b. the suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state c. autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing d. the sudden, severe headache increases muscle tone and can cause further nerve damage
a. the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel
Important history to know specific to the ED
allergies medications including last tetanus vaccination last meal - might vomit upon intubation causing aspiration events precession illness/injury
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? a. respiratory distress and projectile vomiting b. bradycardia and hypertension c. tachycardia and agitation d. hyperthermia
b. bradycardia and hypertension
A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? Select all that apply. a. nystagmus b. facial flushing c. diplopia d. nasal congestion e. headache
b. facial flushing - flushing occurs from the point of the lesion upward d. nasal congestion e. headache - severe Client will experience spots in the visual field and have blurred vision as well.
A patient with a SCI at T5 begins to complain of a severe headache and is diaphoretic and nauseated. Which nursing intervention would not be appropriate? a. place the patient immediately in a sitting position b. lower the patient to a flat, side lying position c. assess for bladder distention d. assess the rectum for a fecal mass
b. lower the patient to a flat, side lying position
The staff educator is precasting a nurse new to the critical care unit when a pt with a T2 spinal cord injury is admitted. The pt is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the pt closely, what would be the nurses most appropriate action? a. prepare to transfuse packed red blood cells b. prepare for interventions to increase the pt's BP c. place the patient in trendelendburg position d. prepare an ice bath to lower core body temperature
b. prepare for interventions to increase the pt's BP -Manifestations of neurogenic shock include decreased BP and HR
A patient is Brough to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hour ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnoses should the nurse associate with this procedure? a. risk for impaired skin integrity b. risk for injury c. risk for autonomic dysreflexia d. risk for suffocation
b. risk for injury If ET intubation is necessary, extreme care is taken to avoid flexing or extending the pt's neck, which can result in extension of a cervical injury.
A nurse is caring for a pt receiving skeletal traction. Due to the patients severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What interventions should the nurse provide in order to prevent these complications? a. perform chest physiotherapy once per shift and as needed b. teach the pt to perform deep breathing and coughing exercises c. administer prophylactic antibiotics as ordered d. administer nebulizer bronchodilators and corticosteroids as ordered
b. teach the pt to perform deep breathing and coughing exercises
A pt is admitted to the ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? a. epidural hemorrhage b. hypertensive emergency c. spinal shock d. hypovolemia
c. spinal shock -in spinal shock, the reflexes are absent, BP and HR fall, and respiratory failure can occur.
Interventions for the pt suffering from PTSD
communication!!! -Create conversations that evoke change by using open ended questions unless you are talking about safety "Talk to me about what brought you into the hospital this time" -Listen to pt, listen to family, and reserve judgement. Use mindfulness -Keep the conversation focused on the client as an individual, while still talking about possible triggers -Motivational interviewing: resist telling them what to do, understand their motivation, listen with empathy, and empower them. Focused on producing reflection and personal change -Affirmation is very important! encourage and re-affirm their self-examination
Assessment of a SCI?
complete neurologic exam CT, MRI, continuous EKG (bradycardia, asystole)
When is surgical management indicated in pts with a SCI?
cord compression fragmented or unstable vertebra bodies cord penetration boney fragments in spinal canal neurological status is deteriorating
A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSC) and asks the nurse to recommend a non pharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? a. spinal manipulation b. acupuncture c. therapeutic touch d. guided imagery
d. guided imagery
A pt who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the pt's current health status is most likely to have precipitated this event? a. the pt received a blood transfusion b. the pt's analgesia regimen was recently changed c. the pt was not repositioned during the night shift d. the pt's urinary catheter became occluded
d. the pt's urinary catheter became occluded -a distended bladder is the most common cause of autonomic dysrefelxia
Clinical manifestations of SCI
depending on the classification... loss of bladder and bowel control loss of sweating marked reduction of BP possibly pain respiratory dysfunction (C4, T1-T11)
What is prolonged exposure therapy?
getting a person to be in an uncomfortable situation for longer periods of time ex: listen to gunfire or an explosion Imaginable (describe, record, listen) or in vivo exposure (confront outside of therapy)
Airway assessment
inspect airway while maintaining cervical stabilization/immobilization observe for vocalization, tongue obstruction, loose teeth, foreign objects, bleeding, vomitus, and edema If mouth is full of blood, turn head to the side You might need to remove dentures, but don't loose them
Inspecting Posterior Surfaces
maintain cervical immobilization and support extremities with suspected injury via logrolling Palpate vertebral column and sphincter for tone - if pt has a spinal injury, the anal sphincter will not pull back/get tight
Assessment of a patient with a SCI
monitor respirations and breathing pattern lungs sounds cough? changes in motor or sensory function - report immediately assess for spinal shock - paralyzed, flaccid, absent reflexes monitor for bladder retention or distention, gastric dilation, and paralytic ileum monitor temperature: potential hyperthermia
Hyper arousal (PTSD)
A constant feeling of being "on guard" and on the lookout for signs of danger May get startled easily Ex: difficulty sleeping, outbursts of anger or irritability, difficulty concentrating
Explain the types of spinal cord injuries
The type of injury refers to the extent on the cord injury. Complete spinal cord injury - loss of both sensory and voluntary motor communication resulting in paraplegia or tetraplegia Incomplete spinal cord injury - communication is not completely absent
Patterns of injury
Airbags - can do a lot of damage and cause secondary injuries like severe burns to the chest and neck from the gas inside Alcohol/narcotic consumption - automatic toxicology screen of blood and urine. do NOT withhold methadone. If an alcoholic pt comes to the hospital for another reason, it might not be the right time to de-tox them. Blunt trauma to the chest - very concerning; deviated tracheostomy's (think tension pnuemo - emergency), flail chest Dog bite - wash it VERY well and automatic tetanus vaccine in the ED regardless of last vaccine (same for if you step on a nail)
Who is at risk for PTSD?
Anyone - it can occur at any point in their life
How can you identify clients that might be at risk for safety considerations in the ED?
Assess if a pt is at risk fro being volatile by assessing their behavior, facial expressions, body language (crossed arms, clenched fist) -soft or loud tone of voice? -do they smell of alcohol with dilated pupils and unable to walk straight? -hx of substance or alcohol abuse -hx of mental health illness -are they a frequent flyer EVERYBODY has the potential to be violent depending on the situation
What medications put elderly patients at a great risk for falls?
Benzodiazepines Lasix IV
What type of pts are seen in the emergency department?
Covid, trauma, chest pain, kidney stones, immunizations, nursing home residents, violent geriatric pts that have not yet been stabilized on their medications
What are some potential problems in a pt with a SCI?
DVT - no calf massage, apply SCDs, or TED hose Orthostatic hypotension Autonomic dysreflexia - s/sx are pounding headache, profuse sweating above injury, nasal congestion, piloerection below the injury, bradycardia, and hypertension
What is the goal of treating pts with PTSD?
strengthen the pt's motivation for seeking help management of symptoms, not curing
Roto Rest Bed
turns from side to side stooling area percussion feature
