Chapter 60
C 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 most appropriate? Insert a rectal stimulant suppository. Teach the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Instruct the patient to avoid all caffeinated and carbonated beverages.
D 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? "I want to be rehabilitated for my daughter's wedding in 2 weeks." "Rehabilitation will be more work done by me alone to try to get better." "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness."
B Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. Prednisone will be tapered over the last 2 weeks of treatment. Oral prednisone may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 3 to 6 months. No serious drug interactions occur between prednisone and acetaminophen.
The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? "I can take the medication with food or milk." "The medication should be started 1 week after paralysis." "I can take acetaminophen with the prescribed medications." "Chances of a full recovery are good if I take the medication"
B 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? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome
A 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? Keep a wrench close or attached to the vest. Use the frame and vest to assist in positioning. Clean around the pins using betadine swab sticks. Loosen both sides of the vest to provide skin care.
C 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? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment
D 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? Impaired urinary elimination related to tetraplegia Risk for impaired tissue integrity related to paralysis Disabled family coping related to the extent of trauma Ineffective airway clearance related to cervical spinal cord injury
A 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? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses
C 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? Urinary catheterization Check for bowel impaction Elevate the head of the bed Administer intravenous hydralazine
A 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? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds
ACEF Penicillin is administered to inhibit further growth of Clostridium tetani. Control of the spasms of tetanus is essential because laryngeal and respiratory spasms cause apnea and anoxia. Morphine can be used to manage pain. A tracheostomy is performed early so mechanical ventilation may be done to maintain respirations. Using polyvalent antitoxin and teaching the correct canning process are done for botulism.
While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate (select all that apply.)? Administer penicillin. Administer polyvalent antitoxin. Control spasms with diazepam (Valium). Teach correct processing of canned foods. Provide analgesia with opioids (morphine). Prepare for tracheostomy for mechanical ventilation.
C 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? Prevent urinary tract infection. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.
BDE 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.)? Drink more milk. Eat 20-30 g of fiber per day. Use oral laxatives every day. Limit caffeinated beverages. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime.
A 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? "I will perform self-catheterization at least six times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."
CEF Self-care for Bell's palsy includes use of corticosteroid medications to decrease inflammation of the facial nerve (cranial nerve VII). Dark glasses and artificial tears protect the cornea from drying because of the inability to close the eyelid. A facial sling may be fitted by the occupational therapist to support muscles and facilitate eating. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.
The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach regarding self-care (select all that apply.)? Administration of antiseizure medications Preparing for a nerve block to manage pain Administration of corticosteroid medications Surgery if conservative therapy is not effective Dark glasses and artificial tears to protect the eyes A facial sling to support the muscles and facilitate eating
