Test 7 - Mobility

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? "I will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating." -Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

Autonomic Dysreflexia

(potentially life threatening emergency!) -HOB elevate 90 degrees -loosen constrictive clothing -assess for full bladder or bowel impaction, (trigger) -administer antihypertensives (may cause stroke, MI, seizure)

Cough Assist

-hands on lower rib cage below diaphragm -as client inhales push upward to expand lungs and cough

A client who has experienced a spinal cord injury has an ipsilateral loss of voluntary motor function and a contralateral loss of pain and temperature sensation. Based on these symptoms, which classification of spinal cord injury does the client have? Paraplegia Tetraplegia Anterior Cord Syndrome Brown Sequard

Brown Sequard -results from damage to a hemisection of the anterior and posterior cord. The effect is an ipsilateral loss of voluntary motor function from the corticospinal tract and proprioception loss with a contralateral loss of pain and temperature sensation from the lateral spinothalamic tracts for all levels below the lesion.

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Eating Breathing Ambulating Transferring to a wheelchair Writing

Eating Breathing Transferring to a wheelchair Writing -Eating, breathing, transferring to a wheelchair, and writing are functional abilities for those with a T4 injury. Ambulation can be performed independently by a client with an injury at T11-S5 injury.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? -Ask the client if there is pain on ambulation. -Ask if the client can walk. -Have the client lie on the back and lift the leg, keeping it straight. -Ask if the client has had a bowel movement.

Have the client lie on the back and lift the leg, keeping it straight. -A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.

Primary Mechanisms of Injury

Hyperflexion Hyperextension Axial Loading/Vertical Compression Excessive Rotation

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? -Insertion of a nasogastric tube -A large volume enema -Digital stimulation -Bowel surgery

Insertion of a nasogastric tube -Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan? -Keeping the head in a neutral position -Wearing the cervical collar when sleeping -Removing the entire collar when shaving -Moving the neck from side to side when the collar is off

Keeping the head in a neutral position -After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.

Cauda Equina Syndrome

L2 to S5; neurogenic bladder & bowel

Anterior Cord Syndrome (Cervical)

Loss of motor function, px and temp sensation; intact tough, position, vibration sensation

Posterior Cord Syndrome (Cervical)

Loss or vibration, crude tough, position sensations; intact motor function

Autonomic Dysreflexia meds

Nitrates, hydralazine

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? -Place the patient in a sitting position. -Call the physician. -Assess the patient for a full bladder. -Assess the patient for a fecal impaction.

Place the patient in a sitting position. -Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower blood pressure.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? -Examine the skin for any area of pressure or irritation. -Examine the rectum for a fecal mass. -Empty the bladder immediately. -Raise the head of the bed and place the patient in a sitting position.

Raise the head of the bed and place the patient in a sitting position. -The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

Nsg. Intervention: Meticulous skin care

Rationale: Aging decreases elasticity and increases dryness

Nsg Intervention: Constipation prevention

Rationale: most SCI pt have constipation, more likely in older ppl

Nsg. Intervention: Annual pap smear/mammogram

Rationale: movement limitations make self exam difficult

Nsg. Interventions: Get flu shots, tetanus q10y,PNA vaccine

Rationale: respiratory complication is most common cause of death after SCI

Nsg Intervention: Preventive measures for osteoporosis

Rationale: women >50 yrs lose bone density

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? -High-Fowler's to allow for maximum hip flexion -Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees -Prone, with a pillow under the shoulders -Supine, with the bed flat and a firm mattress in place

Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees A medium to firm, not sagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress (National Guideline Clearinghouse, 2010). Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 42-1). A prone position should be avoided because it accentuates lordosis.

Conus medullaris Syndrome

T11 to L1 neurogenic bladder & bowel

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? -Cervical collar -Cast -Traction with weights and pulleys -Turning frame

Traction with weights and pulleys -Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? -More back pain than the first postoperative day -Paresthesia in the dermatomes near the wounds -Urine retention or incontinence -Temperature of 99.2° F (37.3° C)

Urine retention or incontinence -may indicate cauda equina syndrome, which requires immediate surgery. An increase in back pain is more common because on the second postoperative day the long-acting local anesthetic, which may have been injected during surgery, will wear off. Although paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if the temperature reaches 101° F (38.3° C).

Voiding w/spastic bladder

Valsalva maneuver and tighten ABD muscles Assess for effectiveness by cath. for residual urine

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. -Venous pooling in the extremities -Bradycardia -Warm skin -Tachycardia -Profuse bilateral sweating

Venous pooling in the extremities Bradycardia Warm skin -Loss of sympathetic innervation causes a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient doe not perspire on the paralyzed portions of the body because sympathetic activity is blocked.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. Young age Female gender Alcohol use Drug abuse European American ethnicity

Young age Alcohol use Drug abuse -The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.

Assess of C4 to C5

apply downward pressure while client shrugs shoulders

Assess L5

apply resistance to dorsiflexion

Assess S1

apply resistance to plantar flexion

Assess L2 to L4

apply resistance while client lifts legs off bed

Assess of C5 to C6

apply resistance while client pulls up arms

Assess C7

apply resistance while client straightens arms

Heterotopic Ossification

bony overgrowth AEB swelling redness, warmth decreased ROM

Bethanechol chloride (urecholine)

cholinergic used to stimulate voiding, given 1 hr before attempt to void

Assess C8

client able to grasp object & form fist

DVT prevention

combo LMWH & rotational bed, SCDs, PCBs

Bowel Retraining

consistent time, high fluid & fiber, rectal stimulation (w/or w/o suppositories)

halo traction/halo vest

device which allows immobilization of cervical spine while allowing early ambulation

Spinal Shock (Etiology)

disrupted communication between upper and lower motor neurons

Lower Motor Neuron Injury

flaccid paralysis

Spinal Shock s/s

flaccid paralysis, loss of reflex activity below injury level, bradycardia, hypotension

Neurogenic shock s/s

hypotension, bradycardia

Dextran (plasma expander)

improve capillary blood flow, prevent/treat hypotension.

botulinum toxin

injectable medication used to treat spasticity

Brown-Sequard Syndrome (Cervical)

ipsilateral loss of motor function, proprioception, vibration, deep touch sensation, contralateral loss of px, temp, light touch sensation

Central Cord Syndrome (Cervical)

loss of motor function pronounced in upper extremities; variable degrees/patterns.

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: -loss of the sensation of pain and temperature on the side opposite the injury. -loss of motor power and sensation in the upper extremities. -preservation of a sense of touch below the level of the lesion. -loss of motor power, pain, and temperature sensation below the level of the lesion.

loss of motor power and sensation in the upper extremities. -Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.

Upper motor neuron injury

muscle spasticity

Autonomic Dysreflexia (Meds)

nitrates & hydralazine

Autonomic Dysreflexia (etiology)

noxious stimulus (bladder distension, constipation)

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? -pain radiating down the posterior thigh -back pain when the knees are flexed -atrophy of the lower leg muscles -Homans' sign

pain radiating down the posterior thigh -A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

Tetraplegia

paralysis of all 4 extremities

Paraplegia

paralysis of lower extremities

C3 to C5

phrenic nerve

Teaching for SCIs

physical mobility & activity skills ADL skills bowel/bladder training medications sexuality education

Assess vulnerability to skin breakdown

press on reddened area no blanching

Decompressive Laminectomy

removal of laminae to allow cord expansion from edema

Spinal Shock (indication of reversal)

return of reflex activity

Autonomic dysreflexia (s/s)

severe hypertension bradycardia headache (sudden onset, severe) stuffiness flushing (above injury) pale (below injury)

anticoagulation

should be initiated within 72 hrs of SCI and continued at least 3 months

First nursing action for pt with autonomic dysreflexia

sit the pt up

Incomplete Injury

some function or movement below injury

Complete Injury

spinal cord is severed or severely damaged, prevents all innervation below injury

Halo Fixator

static traction 4 pins in skull halo attached to vest/cast when spine is stable

Stimulate voiding w/spastic bladder

stroke inner thigh pull pubic/upper thigh hair warm water over perineum tap bladder area (stimulates detrusor muscle)

spinal shock

sudden depression of reflex activity, muscle flaccidity, and absent reflexes in patients iwth SCI. May also see bradycardia and hypotension.

Quadraparesis

weakness in all 4 extremities

Paraparesis

weakness in lower extremities