Hesi Case Study, John Morris, Cerivcal Neck Injury
Which of the following statements best communicates to John the amount of bladder and bowel control he will ultimately have? "In time, you will be able to control yourself completely." "You will never be able to control yourself without the use of enemas and a catheter." "The amount of control you will ultimately have is still unpredictable." "Bladder control will be possible with the use of a catheter but bowel control cannot be accomplished."
"In time, you will be able to control yourself completely." It would be incorrect and falsely reassuring to tell John that complete bladder and bowel function will return. "You will never be able to control yourself without the use of enemas and a catheter." This statement is not correct. As spinal shock subsides, the amount of spinal cord damage will become apparent. John may or may not regain some voluntary control over his bladder and bowel function. If bowel and bladder reflexes remain intact, bladder and bowel training will be possible. Correct: "The amount of control you will ultimately have is still unpredictable." As spinal shock subsides, the amount of spinal cord damage will become apparent. John may or may not regain some voluntary control over his bladder and bowel function. If bowel and bladder reflexes remain intact, bladder and bowel training will be possible. "Bladder control will be possible with the use of a catheter but bowel control cannot be accomplished." This statement is not correct. As spinal shock subsides, the amount of spinal cord damage will become apparent. John may or may not regain some control over his bladder and bowel function. It is possible that both bladder and bowel function could return to some extent.
John wants to see what he looks like. Which of the following approaches is best? Ask the physician if it is all right for John to use a mirror to see himself Provide John with a mirror so that he can see what he looks like Tell John that it is better if he does not use a mirror to see himself right now Show John a picture of a halo ring
Ask the physician if it is all right for John to use a mirror to see himself The physician need not be consulted to determine if John should be allowed to use a mirror to see himself. Correct: Provide John with a mirror so that he can see what he looks like Although it may be difficult for John to see what he looks like with a halo ring in place, it is important that he do so. To regain some control over his situation, he must first know what he is dealing with. Tell John that it is better if he does not use a mirror to see himself right now This approach would not be best. To regain some control over his situation, John must first know what he is dealing with. Show John a picture of a halo ring Showing John a picture of a halo ring would not be the best approach. John is concerned about what HE looks like with a halo ring.
John's blood pressure is closely monitored. His blood pressure has been stable. His current BP is 100/80. To avoid further damage to the spinal cord after the initial spinal cord injury, systolic blood pressure is usually maintained above: 90 mm Hg 100 mm Hg 110 mm Hg 120 mm Hg
Correct: 90 mm Hg To avoid further damage to the spinal cord after the initial spinal cord injury, systolic blood pressure is maintained above 90 mm Hg. Treatment to increase blood pressure is initiated if systolic blood pressure falls below 90 mm Hg. Spinal cord injury causes immediate damage to the spinal cord. Secondary injury may occur as a result of variety of mechanisms, including hypoperfusion and ischemia of the spinal cord that can lead to cell death. To avoid secondary spinal cord injury, systolic blood pressure is maintained above 90 mm Hg and mean arterial blood pressure is maintained between 85-90 mm Hg for the first seven days after acute spinal cord injury. A vasopressor agent such as Intropin (dopamine) may be used to avoid hypotension. 100 mm Hg After acute spinal cord injury, another systolic blood pressure reading would be the point at which treatment to increase blood pressure would be initiated. 110 mm Hg After acute spinal cord injury, another systolic blood pressure reading would be the point at which treatment to increase blood pressure would be initiated. 120 mm Hg After acute spinal cord injury, another systolic blood pressure reading would be the point at which treatment to increase blood pressure would be initiated.
John has been incontinent of hard stool after each evening meal over the past two days. Which interventions are indicated? (Select All) Check to be sure that John is on a high-fiber diet Encourage John to drink plenty of fluids Place a "diaper" on John before his evening meal Place John on a commode after his evening meal Ask the physician to order an enema for John Ask the physician to order a stool softener for John
Correct: Check to be sure that John is on a high-fiber diet John is constipated with hard stool. Interventions to alleviate the problem and avoid fecal impaction are indicated. A diet high in fiber should increase bowel motility and help avoid hard stools and fecal impaction. Correct: Encourage John to drink plenty of fluids John is constipated with hard stool. Interventions to alleviate the problem and avoid fecal impaction are indicated. If John's fluid intake is increased, his stools should become softer. Place a "diaper" on John before his evening meal Placing a diaper on John would be demoralizing and could threaten his self-concept. John is a young adult, anxious to maintain his independence and proceed with his maturity. Correct: Place John on a commode after his evening meal Since John has already shown a tendency to pass stool by reflex action after his evening meal, placing him on the commode at this time would increase the chance that he would have a bowel movement in a more normal fashion. Applying pressure to John's abdomen while he is on the commode would encourage reflex evacuation of stool. Ask the physician to order an enema for John An enema should be used only when other measures have failed. Bowel distention caused by an enema could cause autonomic dysreflexia (hyperreflexia), a serious complication of spinal cord injury. Correct: Ask the physician to order a stool softener for John John is constipated with hard stool. Interventions to alleviate the problem and avoid fecal impaction are indicated. A stool softener should help to soften stool so it can more easily be evacuated.
Which of the following interventions are planned to help reduce John's risk for pressure ulcers? (Select All) Ensure that sheets remain clean and dry Facilitate a gradual weight loss Inspect skin frequently Ask John to report any discomfort
Correct: Ensure that sheets remain clean and dry Sheets must be kept clean and dry. Wet, dirty sheets are irritating to the skin and increase susceptibility to skin breakdown. Facilitate a gradual weight loss At this time, weight maintenance is indicated, not weight loss or gain. Immediately after spinal cord injury, a state of catabolism exists. Weight loss can happen quickly. Weight loss, with decreased fat and protein, would increase risk for pressure ulcers. After the acute period of spinal cord injury, patients are predisposed to weight gain. Correct: Inspect skin frequently Skin assessment is critical for patients with spinal cord injury. All skin areas, especially pressure points, should be checked frequently for redness, pallor, or excoriation. If evidence of pressure is noted, pressure relief at the site should be provided. Patient inability to feel pain or respond to pressure or pain makes frequent skin inspection imperative. Graduated compression stockings should be removed so that skin can be inspected. Prevention of pressure ulcers will be an ongoing concern for John. Ask John to report any discomfort Relying on John to report skin discomfort is not appropriate and would not reduce risk for pressure ulcers. Even though some sensation is present, John's ability to accurately sense tissue pressure or damage is probably minimal at this time.
Autonomic dysreflexia (hyperreflexia) can be a life-threatening complication of spinal cord injury. The most common precipitating cause is: a distended bladder or rectum clot formation at the site of spinal cord injury damage to autoregulatory centers of the brain position change
Correct: a distended bladder or rectum The most common causes of autonomic dysreflexia are bladder distention and fecal impaction. clot formation at the site of spinal cord injury Clot formation at the site of spinal cord injury does not lead to autonomic dysreflexia (hyperreflexia). damage to autoregulatory centers of the brain Autonomic dysreflexia (hyperreflexia) is associated with spinal cord injury, not brain injury. position change Position changes generally do not precipitate autonomic dysreflexia (hyperreflexia).
John's respiratory status is also closely monitored. Because of cervical spine injury, respiratory function will be affected. Because of his injury, John is likely to: hypoventilate hyperventilate
Correct: hypoventilate Because of spinal cord injury at C8, John is likely to hypoventilate. With injury at C8, diaphragm muscle function will be intact but not all accessory muscle function will be present. Vital capacity and tidal volume will likely be decreased and respiratory muscle fatigue may occur. Respirations will be shallow and slow. hyperventilate John is not predisposed to hyperventilation as a result of spinal cord injury at C8.
As you talk with John and apply lotion to back, he excitedly tells you that he feels movement in his legs. You appropriately explain to John that: involuntary muscle movement will return to his legs, perhaps followed by some voluntary movement full range of involuntary and voluntary movement will gradually return to his legs the movements in his legs may precede a seizure
Correct: involuntary muscle movement will return to his legs, perhaps followed by some voluntary movement John will regain involuntary muscle movement in his legs as spinal shock resolves. Some voluntary movement may also return, depending on the extent of trauma to John's spinal cord. full range of involuntary and voluntary movement will gradually return to his legs John will not regain the full range of voluntary and involuntary muscle movement in his legs. the movements in his legs may precede a seizure The movement in John's legs is unrelated to seizure activity.
John received IV Solu-Medrol (methylprednisolone) when first admitted. The drug was administered to: minimize post-injury spinal cord damage prevent spinal infection decrease movement of the spine stabilize blood pressure
Correct: minimize post-injury spinal cord damage Spinal cord injury causes immediate damage to the spinal cord. Secondary injury may occur as a result of variety of mechanisms, including inflammation and edema. Given within eight hours of spinal cord injury, Solu-Medrol (methylprednisolone) may minimize spinal cord damage from post-injury edema and other effects, and result in greater preservation of motor and sensory function. An IV bolus dose is given, followed by an IV drip given over 23 hours. High-dose steroid therapy with Solu-Medrol (methylprednisolone) for treatment of acute spinal cord injury is controversial. Potentially harmful side effects and adverse effects may occur with therapy, and benefit of therapy is not predictable. Possible harmful effects of high-dose steroids include gastrointestinal bleeding and infection. prevent spinal infection Solu-Medrol (methylprednisolone), a corticosteroid, was not given to prevent infection. Corticosteroids may mask signs and symptoms of infection. decrease movement of the spine Solu-Medrol (methylprednisolone), a corticosteroid, was not given to decrease movement of the spine. Immobilization of the spine is achieved with other means. stabilize blood pressure Solu-Medrol (methylprednisolone), a corticosteroid, was not given to stabilize blood pressure.
In response to John's new condition. Which nursing action is indicated? Cover John with a blanket Take John's temperature Check John's halo ring pin sites Raise John to a sitting position
Cover John with a blanket Covering John with a blanket is not indicated. John may be experiencing a serious complication of spinal cord injury that you should recognize and know how to treat. Take John's temperature Checking John's temperature is not indicated. John may be experiencing a serious complication of spinal cord injury that you should recognize and know how to treat. Check John's halo ring pin sites Checking John's halo ring pin sites is not indicated. John may be experiencing a serious complication of spinal cord injury that you should recognize and know how to treat. Correct: Raise John to a sitting position Raising the head of the bed to 45 degrees is the first action to take for a patient with John's symptoms. John is exhibiting signs and symptoms of the potentially life-threatening condition, autonomic dysreflexia (hyperreflexia). This condition occurs in patients with spinal cord injury (T6 and above, more common with cervical injuries), only after spinal shock has resolved. Autonomic dysreflexia is characterized by sudden headache, severe hypertension that can lead to stroke, sweating and flushing above the level of injury, and cool pale skin with gooseflesh (piloerection) below the level of injury. Raising John to a sitting position will elevate his head and help reduce blood pressure by encouraging pooling of blood in the legs. Blood pressure should be checked, and a physician should be notified. The cause of the problem should be identified and corrected.
Which of the following would be useful interventions with John to facilitate removal of respiratory secretions? (Select All) Fluid restriction Pursed lip breathing Assisted coughing Prone positioning Humidification
Fluid restriction Fluid restriction is not indicated. To make sure respiratory secretions are not thick, fluid intake is usually increased. With adequate or increased hydration, secretions should be thinner and easier to eliminate. Pursed lip breathing Pursed lip breathing (exhaling through pursed lips) prolongs expirations and allows for a more complete exhalation. It is indicated for persons with emphysema to minimize air trapping. It is not used to facilitate secretion removal in a person with a spinal cord injury. Correct: Assisted coughing Assisted coughing, also called "quad coughing" involves applying pressure (in and up) between the umbilicus and the xiphoid process as the person exhales during a cough. It is useful for persons with spinal cord injuries who have ineffective cough because of inadequate muscle function. Assisted coughing is done frequently with John, and he is able to cough productively. John is also assisted in using an incentive spirometer every 1-2 hours. Breath sounds are checked frequently. Arterial oxygen saturation (SpO2) is monitored. Prone positioning Prone positioning is contraindicated at this time. Immediately after spinal cord injury, this position is not possible because of traction restrictions and the need to keep the spinal column stable. Correct: Humidification When secretion clearance is problem, humidification is useful in making respiratory secretions thinner. Thinner secretions are more easily mobilized and eliminated. Humidification is being provided for John by nebulizer, to help keep respiratory secretions thin.
John's Foley catheter is discontinued. Given the pathophysiology of John's spinal cord injury, which of the following nursing diagnoses now applies? Functional Incontinence Reflex Incontinence Stress Incontinence Total Incontinence Urge Incontinence
Functional Incontinence The nursing diagnosis Functional Incontinence applies when a person is unable to reach the bathroom before passing urine. Functional Incontinence does not apply with John. Correct: Reflex Incontinence The nursing diagnosis Reflex Incontinence applies to John. Reflex Incontinence is present when involuntary reflex voiding occurs, as after spinal cord injury. Because the return of reflex voiding may be gradual, straight catheterizations will be needed every 3-4 hours to avoid bladder distention and stasis of urine. Urinary stasis increases risk for urinary tract infection. Bladder distention must be avoided to prevent autonomic dysreflexia. Stress Incontinence The nursing diagnosis Stress Incontinence applies when an increase in intraabdominal pressure causes involuntary loss of urine. Stress Incontinence does not apply with John. Total Incontinence The nursing diagnosis Total Incontinence applies when passing of urine occurs unpredictably and without awareness. Total Incontinence does not apply with John. Urge Incontinence The nursing diagnosis Urge Incontinence applies when a strong desire to void and passing of urine occur involuntarily. Urge Incontinence does not apply with John.
John has a nasogastric (NG) tube for which of the following reasons? He is at risk for constipation He has paralytic ileus He is probably unable to swallow He is at risk for stress ulcers
He is at risk for constipation John is at risk for constipation, but this is not the reason he has a nasogastric tube. Correct: He has paralytic ileus Because of spinal shock, paralytic ileus (atonic bowel, lack of intestinal motility) is often present after spinal cord injury. Bowel decompression with a nasogastric (NG) tube to suction prevents abdominal distention, which would restrict ventilation. It also prevents nausea and vomiting. Regurgitation of stomach contents would increase risk for aspiration. He is probably unable to swallow John may be unable to swallow, but this is not the reason he needs an NG tube. He is at risk for stress ulcers Although John is at risk for stress ulcers, this is not the reason he needs an NG tube.
To prevent infection at the pin sites, which of the following nursing interventions apply? (Select All) Remove pins each shift for cleaning Cleanse pin sites and remove crust as necessary Use sterile technique when cleaning pin sites
Remove pins each shift for cleaning Pins should not be removed. The pins anchored in John's skull are part of the apparatus that maintains alignment of John's spine. Removing the pins could result in misalignment of John's spine and further injury. Correct: Cleanse pin sites and remove crust as necessary Pin sites should be checked frequently and cleaned as needed, with exudate (crust) removed. Accumulated exudate can contain microorganisms and increase the possibility of infection. Pin sites are usually cleaned with normal saline. Agency protocols for cleaning pin sites (and possibly applying antibiotic ointment) should be followed. Correct: Use sterile technique when cleaning pin sites Sterile technique should be used when cleaning any open area to prevent introduction of bacteria and decrease risk for infection.
You recall the importance of appropriate emergency care when a spine injury is suspected. Which of the following is indicated in all cases of possible spine injury? Restraints to prevent injury secondary to seizures Administration of 100% oxygen to prevent hypoxemia Immobilization of the spine to prevent further injury Endotracheal intubation to prevent respiratory distress
Restraints to prevent injury secondary to seizures Restraints are not indicated for a person with a suspected spine injury, except to ensure that the person does not fall off a transport stretcher. Seizures are not common after spine or spinal cord injury, and if a seizure were to occur, restraint would be unsafe. Administration of 100% oxygen to prevent hypoxemia Administration of 100% oxygen might be indicated for a person with a spine injury, if respiratory distress is present. However, it is not indicated in all cases of suspected spine injury. Correct: Immobilization of the spine to prevent further injury It is imperative that the spine be immobilized whenever a spine injury is a possibility. The spine protects the delicate spinal cord. Trauma to the spine can lead to spinal cord damage. Trauma to the spinal cord can be prevented or reduced with early immobilization of the spine whenever spine injury is suspected. The spine should be immobilized as soon as possible with a backboard with straps, a rigid cervical collar, and supportive blocks. Immobilization is designed to prevent hyperflexion, hyperextension, and rotation of the spine, which could cause cord injury if a fracture is present. Endotracheal intubation to prevent respiratory distress Intubation might be required when providing emergency care for a person with a spine injury, if respiratory distress is present. However, it is not indicated in all cases of suspected spine injury.
John looks at himself in a mirror. He quickly closes his eyes and starts cursing and yelling at you. Which initial approach is best? Tell John that his behavior is inappropriate and unacceptable Request an order for Valium (diazepam) Remain quietly at John's bedside Ask that another nurse be assigned to John's care
Tell John that his behavior is inappropriate and unacceptable John needs to express anger he feels about his new body image and functional losses. He also needs to know that there are limits to the expression of this anger. However, your initial response to his comments should be different. Request an order for Valium (diazepam) John is reacting to his new body image and functional losses. He needs to express his anger. Tranquilizers will not help John deal with his new body image. Correct: Remain quietly at John's bedside John is reacting to his new body image and functional losses. He will grieve the loss of his former appearance and functions. He needs to express his anger. He also needs to know that there are limits to the expression of this anger, and it will be important to tell him this. Initially, however, John should feel comfortable talking with you so that he can express his feelings. Remaining quietly at his bedside will help foster a relationship. Ask that another nurse be assigned to John's care John is not reacting to you. He is expressing anger about his new body image and functional losses. Requesting reassignment because of his angry outburst would be inappropriate and unprofessional.
John is a 19-year-old college student. He has been working as a lifeguard for the summer. While demonstrating a jackknife dive, he lost control of his body and hit the water hard, losing consciousness. He suffered a flexion fracture of the cervical spine with spinal cord injury.
The Scenario
You check John's Foley catheter, which is draining clear, yellow urine. John has a Foley catheter to alleviate which of the following problems? Urinary tract infection Urinary retention Urinary incontinence
Urinary tract infection John does not have a urinary tract infection. A Foley catheter increases risk for urinary tract infection. Correct: Urinary retention John has a Foley catheter because of urinary retention. Spinal shock causes loss of all reflexes controlled by spinal segments below the level of the injury. In John's case (injury at C8) the micturition reflex is one of the reflexes that has been lost. Loss of the micturition reflex, in conjunction with loss of voluntary bladder control secondary to spinal injury, results in urinary retention. Urinary incontinence John is not predisposed to incontinence at this time. Incontinence may be a problem after spinal shock resolves, if elimination of urine occurs involuntarily.
Physiological improvement (sensation in John's legs) exhibited by John probably indicates resolution of: autonomic dysreflexia spinal shock Cushing's triad Horner's syndrome
autonomic dysreflexia The improvement noted in John's physiological status since admission is not related to autonomic dysreflexia. Autonomic dysreflexia (hyperreflexia) is a complication of spinal cord injury that occurs in patients with spinal cord injuries at T6 and above. It involves exaggerated sympathetic nervous system responses with severe hypertension that can lead to stroke. It does not occur immediately after spinal cord injury. Correct: spinal shock The return of sensation in John's legs probably indicates that spinal shock is resolving. Spinal shock is a temporary response that occurs immediately after spinal cord injury. Spinal shock involves loss of sensation and all motor activity (both voluntary and reflex) below the level of spinal injury. It is reflected in a flaccid paralysis. In addition, with spinal cord injuries above T6-T7, there is loss of reflex sympathetic vasomotor tone. This causes vasodilation and peripheral pooling of blood, with decreased cardiac output, hypotension, bradycardia, and warm dry skin (neurogenic shock). Cushing's triad Cushing's triad (systolic hypertension with widening pulse pressure, bradycardia, and changing respiratory pattern) is a sign of greatly increased intracranial pressure. It occurs with brain decompensation and loss of autoregulation. It is not associated with spinal cord injuries. Horner's syndrome Horner's syndrome accompanies spinal cord injuries at T1 and above. It is not responsible for the disparity seen in the clinical features noted immediately after a spinal cord injury and those seen later. Horner's syndrome is characterized by ptosis (drooping) of the eyelid, miosis (constriction) of the pupil, and absence of sweating over the affected side of the face.
Work has been done on John's plan of care. The main long-term goal of nursing care when working with John is to: foster dependency on health team members promote independence facilitate family involvement in John's rehabilitation prevent social isolation
foster dependency on health team members Although John will require the assistance of all members of the health team, dependency should not be encouraged or facilitated. Correct: promote independence Independence is the ultimate goal to be achieved by John. Independence and self-reliance are especially important for John, a maturing young adult. With cervical spine injury at C8, John will have wheelchair mobility, and has potential for independence in activities of daily living. facilitate family involvement in John's rehabilitation Involvement of John's family in his rehabilitation is important but it is not a primary goal of care. It is a means to another end. prevent social isolation While it is important to prevent John from becoming isolated, this is not the primary goal of care.
All spinal injuries are serious. However, cervical spine injuries are especially life-threatening. This is because damage to the spinal cord at the level of the cervical spine is likely to cause: seizures hemorrhage dysrhythmias respiratory distress
seizures Seizures are not the major concern when a person has a cervical spine injury. hemorrhage Hemorrhage is not the major concern when a person has a cervical spine injury. dysrhythmias Dysrhythmias are not the major concern when a person has a cervical spine injury. Correct: respiratory distress When a person has a cervical spine injury, assessing airway and breathing is critical. Cervical spine injuries that result in spinal cord damage affect respiratory muscle function in varying degrees, depending on the level of injury. If not immediately ventilated, a patient with a high cervical spine injury may die. The phrenic nerve, which innervates the diaphragm, arises from cervical segments C3-C5. Loss of phrenic nerve innervation causes lack of diaphragm movement and results in respiratory failure. A patient with a spinal cord injury at C4 or above usually requires assisted ventilation. With lower cervical spine injuries, respiratory function is variably affected, because of the loss of function of other muscles of respiration. Even with injuries of the thoracic spine, respiratory insufficiency is possible, since some muscles that assist with respiration are innervated through thoracic nerve roots.