spinal cord (evolve)
A. Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal complaints are not characteristic manifestations.
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible 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
A. monitoring neurologic status B. administering corticosteroids D. Discussing long-term care issues with the family Close monitoring of sensory and motor function is important to prevent further deterioration of neurologic status as a result of spinal cord edema. Corticosteroids are administered to minimize the inflammation associated with the injury. Close monitoring of respiratory status for possible need of ventilator support. Remember "A-B-C's," airway, breathing, and circulation. Monitoring and maintaining hemodynamic status may require immediate attention related to increased intracranial pressure resulting in hypotension and bradycardia. The discussion of long-term care issues with the family is not appropriate in the acute phase of spinal cord injury.
A 15 year old is admitted to the intensive care unit (ICU) with a spinal cord injury. The MOST appropriate nursing interventions for this adolescent are: A. monitoring neurologic status B. administering corticosteroids C. Monitoring for respiratory complications D. Discussing long-term care issues with the family E. Monitoring and maintaining hemodynamic status
C. Assess bowel movements for frequency, consistency, and volume. The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.
A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is mostappropriate? A. Insert a rectal stimulant suppository. B. Teach the patient to gradually increase intake of high-fiber foods. C. Assess bowel movements for frequency, consistency, and volume. D. Instruct the patient to avoid all caffeinated and carbonated beverages.
C. Encourage him to verbalize his feelings. To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will likely need a wheelchair and have impaired sexual function. Resuming a racing career is unlikely. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.
A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. Prevent urinary tract infection. B. Monitor the patient every 15 minutes. C. Encourage him to verbalize his feelings. D. Teach him about using the gastrocolic reflex.
B. Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.
A 64-yr-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2°F (36.2°C). Which physician order should the nurse complete first? A. Obtain a 12-lead ECG and arterial blood gases. B. Rapidly administer 1000 mL normal saline solution IV. C. Administer norepinephrine (Levophed) by continuous IV infusion. D. Carefully insert a nasogastric tube and an indwelling bladder catheter.
B. Eat 20-30 g of fiber per day. D. Limit caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.
A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? A. Drink more milk. B. Eat 20-30 g of fiber per day. C. Use oral laxatives every day. D. Limit caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. F. Establish bowel evacuation time at bedtime.
D. "With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at his or her highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.
A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."
B. Spinal shock syndrome About 50% of people with acute spinal cord injury experience spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome
A. Keep a wrench close or attached to the vest. A halo vest is used to provide cervical spine immobilization while vertebrae heal. A wrench should accompany the halo vest at all times in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with half strength hydrogen peroxide, normal saline, or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.
The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A. Keep a wrench close or attached to the vest. B. Use the frame and vest to assist in positioning. C. Clean around the pins using betadine swab sticks. D. Loosen both sides of the vest to provide skin care.
C. Respiratory assessment Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.
The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment
A. "I will perform self-catheterization at least six times per day." Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.
The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."
D. Ineffective airway clearance related to cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Although all are appropriate nursing diagnoses for a patient with a cervical spinal cord injury, respiratory needs are always the highest priority (ABCs).
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? A. Impaired urinary elimination related to tetraplegia B. Risk for impaired tissue integrity related to paralysis C. Disabled family coping related to the extent of trauma D. Ineffective airway clearance related to cervical spinal cord injury
A. Bradycardia Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses
C. Elevate the head of the bed Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.
Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Check for bowel impaction C. Elevate the head of the bed D. Administer intravenous hydralazine