Mr. John Wright HESI

Mrs. Wright is terribly distraught. In a meeting with you and the physician, she asks if her husband will be "this paralyzed" from now on. Which of the following responses is accurate?

"Immediately after injury, loss of all function is frequently present. Some function may be regained over time." This comment to Mrs. Wright would be accurate and informative, while not providing false reassurance. Because of spinal shock, immediately after injury, patients with spinal cord injury frequently (but not always) are areflexic and have total loss of motor function below the level of injury, and sometimes above the level of injury. As spinal shock resolves, the long-term effects of injury become more evident. In patients like Mr. Wright, with an intact spinal cord, function may return, although this happens in highly variable degrees.

Solu-Medrol (methylprednisolone) is ordered to infuse at a dosage of 5.4 mg/kg/hour for 23 hours. You check the physician's calculations. Given Mr. Wright's weight of 90 kg, Correct mg of drug should infuse per minute.

8.1

Mr. Wright's hemodynamic status is also closely monitored. To avoid further damage to the spinal cord after the initial spinal cord injury, systolic blood pressure is maintained above:

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.

Because some sensation has returned, Mr. Wright's spinal cord injury is classified as which of the following?

An incomplete injury Incomplete spinal cord injuries are those in which some degree of motor and/or sensory function below the level of cord injury is evident, after the resolution of spinal shock. The term "incomplete injury" has also been defined as preservation of motor and sensory function in the last sacral segment (S4-S5). With incomplete injuries, the amount of function that returns as spinal shock resolves is not necessarily indicative of the amount of function that ultimately will be present. Improvement in function can occur over time. Functional level of injury may descend two levels.

Which of the following drugs are available if needed to maintain Mr. Wright's blood pressure and pulse rate at desired levels? Select all that apply (there are 3 correct answers).

Atropine sulfate, Intropin (dopamine) , Dobutrex (dobutamine)

To evaluate the effectiveness of interventions for Mr. Wright's pulmonary care, which of the following are monitored? Select all that apply (there are 6 correct answers).

Breath sounds, White blood cell count (WBC), Pulse rate , Oxygen saturation, Temperature, Amount and character of sputum

Mr. Wright's BP is 210/110. Blood pressure monitoring every five minutes is initiated. Besides blood pressure, what other assessment is important at this time?

Check the patency of Mr. Wright's Foley catheter The most common causes of autonomic dysreflexia are bladder distention and fecal impaction. It would be appropriate to check the patency of Mr. Wright's Foley catheter.

Assessing cranial pin sites is an important component of Mr. Wright's care. Which of the following would you investigate further?

Clear fluid drainage from the pin sites Clear fluid drainage from pin sites may be normal (expected as a result of normal inflammation). However, drainage could be cerebrospinal fluid (CSF), which would not be normal. CSF drainage from pin sites is NOT expected -- it would indicate dural tear and require immediate medical intervention. Drainage should be checked to see if it is CSF. CSF creates a "halo" effect when it dries on bed linens or a gauze pad.

Mr. Wright is transferred to a Rehabilitation Unit 15 days after his injury. As rehabilitation begins, Mr. Wright's disabilities are evaluated using which of the following?

Functional Independence Measure (FIM) After the acute phase of spinal cord injury, the Functional Independence Measure (FIM) is used to assess functional disabilities resulting from injury and the need for assistance. Use of this tool allows for standardized measurement and understanding across caregivers.

Identifying when spinal shock resolves is important. Which of the following would be consistent with the resolution of spinal shock? Select all that apply (there are 3 correct answers).

Gooseflesh is apparent on Mr. Wright's skin when he is bathed Because of spinal shock, immediately after injury, patients with spinal cord injury frequently (but not always) are areflexic and have total loss of motor function below the level of injury, and sometimes above the level of injury. Gooseflesh and shivering are sympathetic nervous system responses that are absent when spinal shock is present. Their return would indicate that spinal shock was resolving. Tugging at Mr. Wright's Foley catheter causes anal sphincter contraction Because of spinal shock, immediately after injury, patients with spinal cord injury frequently (but not always) are areflexic and have total loss of motor function below the level of injury, and sometimes above the level of injury. The bulbocavernosus reflex (anal sphincter contraction in response to tugging at the Foley catheter or squeezing of the glans penis) is absent when spinal shock is present. Its return would indicate resolution of spinal shock. With resolution of spinal shock, other reflexes below the level of injury would return as well Mr. Wright's pulse rate increases without medication Because of spinal shock, immediately after injury, patients with spinal cord injury frequently (but not always) are areflexic and have total loss of motor function below the level of injury, and sometimes above the level of injury. There is also a neurogenic shock, which results in loss of sympathetic vasomotor tone. This results in unopposed parasympathetic control of heart rate, and subsequent bradycardia. Bradycardia associated with spinal shock spontaneously resolves as spinal shock ends. Pulse rate would increase to normal range.

During this immediate post-injury period, which of the following are also major concerns when caring for Mr. Wright? Select all that apply (there are 4 correct answers).

Maintaining normothermia, Preventing pressure ulcers , Preventing deep vein thrombosis (DVT) , Preventing infection

Which of the following drugs is an antihypertensive medication with a short duration of action that could be used to normalize Mr. Wright's blood pressure, if needed?

Nitropress (nitroprusside) IV Nitropress (nitroprusside) is an antihypertensive drug that has a direct action on blood vessels, causing vasodilation. The drug is administered reconstituted and then diluted in dextrose 5% in water for titrated infusion. The infusion should be protected from light. Onset of drug action is rapid (1-2 minutes) and duration of action is short (1-10 minutes).

Trauma patients are often in shock. Hypotension is common to all types of shock. Which of the following assessments is important in helping distinguish between neurogenic shock and other types of shock?

Pulse rate In neurogenic shock, pulse rate is slow. In other forms of shock, pulse rate becomes rapid. Poor tissue perfusion and poor oxygenation characterize all forms of shock (hypovolemic shock, cardiogenic shock, septic shock, neurogenic shock). For all types of shock except neurogenic shock, heart rate and respiratory rate increase as compensatory efforts to maintain adequate tissue oxygenation. With neurogenic shock, a compensatory increase in heart rate cannot occur because there is loss of nerve impulse transmission and sympathetic vasomotor tone. This results in unopposed parasympathetic control of heart rate, and subsequent bradycardia.

Which of the following nursing diagnoses addresses Mr. Wright's urinary elimination problem?

Reflex Incontinence The nursing diagnosis Reflex Incontinence applies to Mr. Wright. Reflex Incontinence applies when involuntary reflex voiding occurs, as after spinal cord injury. Because the return of reflex voiding may be gradual, straight catheterizations are being done every 3-4 hours to maintain bladder volume under 300 mL. A distended bladder must be avoided to prevent autonomic dysreflexia.

For a patient with cervical traction using tongs, if one cranial pin became disconnected from the skull, which immediate action would you implement FIRST?

Remove the traction weights

Which of the following apply to Mr. Wright? Select all that apply (there are 4 correct answers).

Risk for Impaired Skin Integrity, Risk for Infection , Risk for Disturbed Body Image , Ineffective Breathing Patterns

As you plan Mr. Wright's care, you realize that his clinical presentation and symptoms reflect which phenomenon often seen immediately after spinal cord injury?

Spinal shock Mr. Wright's clinical presentation is consistent with spinal shock. Spinal shock involves loss of all motor activity (both voluntary and reflex) below the level of spinal injury. It is reflected in a flaccid paralysis. In addition, loss of reflex sympathetic vasomotor tone causes vasodilation and peripheral pooling that results in a neurogenic shock, with hypotension, bradycardia, and warm dry skin.

For assisted ventilation, Mr. Wright needed intubation. Nasotracheal intubation was preferred over orotracheal intubation because it:

made it unnecessary to hyperextend his neck

Your next action should be to

take Mr. Wright's blood pressure and notify the physician stat It is imperative that Mr. Wright's blood pressure be taken and the physician be notified. Mr. Wright is exhibiting signs and symptoms of autonomic dysreflexia (hyperreflexia), a complication common 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.