Spinal cord injury 3.2-3.5

What are priorities of care immediately following a spinal cord injury? SATA 1. Emptying bladder 2. Decreasing resp rate 3. Maintain alignment 4. Preventing secondary complications 5. Promoting BM 6. Reducing anxiety 7. Preserving function

3, 4, 6, 7 (Follow ABCs in order to start care)

Your SCI patient is starting to sweat, their face flushes and they are feeling nauseated goose bumps and cold skin below the injury. What is your first action? 1. Apply nitro paste 2. Do bladder scan 3. Check if there are any wrinkles in their sheets 4. Assess for signs of stroke

3. Check if there are any wrinkles in their sheets Also elevating the head of the bed is really helpful! Helps with BP Noxious stimulus e.g. constipation/impaction pressure to skin from sitting restrictive clothing overstretched or irritated bladder

What type of breathing might you assess/hear from a patient who has a C4 injury? 1. Crackles, diminished 2. Labored 3. Diminished, ronchi

3. Diminished, ronchi No use of intercostal muscles May need mechanical intervention

What might a patients vital signs look like after a spinal cord injury? 1. Increased resp rate, increased BP, increased temp, increased pulse 2. Increased resp rate, increased BP, decreased pulse, decreased temp 3. Decreased resp rate, decreased BP, increased pulse, decreased temp 4. Increased resp rate, decreased BP, decreased pulse, decreased temp

4. Increased resp rate, decreased BP, decreased pulse, decreased temp Cardiovascular system- decrease heart rate, decrease BP, peripheral vasodilation hard time regulating temp because sensations arent going to get up to the hypothalamus to help regulate temperature lost intercostal and accessory breathing to help with deep breathing

A patient with a C4 is unable to use their intercostal and accessory muscles to breathe. What might be some interventions? 1. Albuterol 2. Simple mask 3. Nasal cannula 4. Mechanical ventilation

4. Mechanical ventilation

Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin

A. an indwelling catheterization because of reflex bladder, bladder empties in response to stretch, so there is frequent leakage

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be

B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.

An initial incomplete spinal cord injury often results in complete cord damage because of a. edematous compression of the cord above the level of the injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury

C. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. 1. how to use a sign board 2. transfer techniques 3. information about impulse control 4. time adjustment to complete activities 5. safety precautions for transferring

Correct Answer: 1,2,5 Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.

Correct Answer: 4 Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

With a patient who has autonomic dysreflexia what are some ways to decrease hypertension? 1. Nitropaste 2. Methylprednisonlone 3. oxybutynin 4. tolterodine tartrate 5. Nifedipine sublingual 6. Hydralazine IV 7. Heparinn

1, 5, 6 Nitropaste will reduce BP but also cause headaches (some people refuse to have it) Nifedipine sublingual - calcium channel blocker Hydralazine IV (vasodilator) Methylprenisonlone is what is given up to 8 hours after a ISC to help reduce inflammation and swelling oxybutynin tolterodine tartrate is given to help with bladder training Heparin is given to help reduce DVT

Your patient is experiencing constipation, what diet would you patient who has an ISC be? 1. High carb 2. High Fat 3. High fiber/ fluids 4. High potassium

1. High fiber/ increase fluid intake In their orders you may find: Stool softener Rectal stimulation (digital) Fleets enema Consistent time for bowel elimination; 30 minutes after eating (digital stimulation)

Your patient feels cold inside yet is warm to the touch and has dry skin and their BP is low. What is consistent with these findings? 1. Autonomic Dysreflexia 2. Spinal Shock 3. Neurogenic shock 4. TIA

3! Due to loss of sympathetic nervous system innervation Look for low blood pressure and low pulse for a patient with a T6 or higher injury

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.

Secondary injuries to ISCs can cause further permanent damage, what medication is most likely going to be ordered ASAP immediately after realizing they have a spinal cord injury within 3-8 hrs? 1. Nitro paste 2. Methylprednisonlone 3. Carvedilol 4. Ciprofloxacin

Methylprednisonlone- to prevent secondary injury Rationale: Steroids help Decrease inflammation and swelling Reduces edema and ischemia Increases odds of moving to a higher motor/sensory category

Flaccid bladder is when the bladder fills up but doesn't empty 1. true 2. false

TRUE Overdistention with overflow incontinence

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A) Bradycardia B) Hypertension C) Neurogenic spasticity D) Bounding pedal pulses

Correct Answer(s): A Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer(s): B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."

Correct Answer: 2 Rationale: A halo device will allow the patient to be mobile since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.

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.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.

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

Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

What are some other complications you want to prevent for a patient who has ISC and you want to prevent respiratory issues? SATA 1. Administer prn albuterol 2. Quad Cough 3. Incentice spirometer 4. Tylenol

2, 3 You want to prevent pneumonia and atelectasis

Which of the following signs and symptoms in a patient with a T6 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

The nurse wants to put compression stockings on a patient with a ISC. Why? 1. Maximizes blood flow 2. Prevent DVT 3. Prevent a stroke 4. Prevent skin breakdown

2 Prevent DVT Ted hose/SCDs Heparin/Lovenox subq initially Coumadin (eat what you typically eat, no more or no less potassium) Adequate fluid intake

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temp, increasing pulse, increasing resp, decreasing BP 2. Increasing temp, decreasing pulse, decreasing resp, increasing BP 3. Decreasing temp, decreasing pulse, increasing resp, decreasing BP 4. Decreasing temp, increasing pulse, decreasing resp, increasing BP

2. Increasing temp, decreasing pulse, decreasing resp, increasing BP A change in vital signs may be a late sign of intracranial pressure. Trends include increasing temp and BP, and decreasing pulse and resp. Resp irregularities also may occur

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer(s): A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

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

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.

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

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

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

Correct Answer: 3 Rationale: Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.