NUR 213: Spinal Cord Injury

Which nursing action would have the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process? 1. Removing the cervical spine collar 2. Monitoring for autonomic dysreflexia 3. Implementing the logrolling technique 4. Administering the prescribed pain medication

3. Implementing the logrolling technique Logrolling technique would help prevent exacerbation of the original injury.

health promotion

- active ROM q2h - manage pain - plenty of fluids - use assistive devices to help with ADLs - consider dropfoot - PT/OT involvement - prevent DVTs - special wheelchairs - deep breathing and use of incentive spirometer - nutrition teaching (high fiber and adequate fluids, high protein, high calcium, low calorie)

Injuries higher than C4

Paralysis of respiratory muscles AND all four extremities (quadriplegia) "C3 through C5, keep patient alive."

Complete vs. Incomplete

Complete: no function below the injury Incomplete: allows some function (limited movement and/or sensation)

Impaired physical mobility

due to fatigue, decreased muscle strength, pain or advanced dementia

Ineffective breathing patterns

- Increased risk for pneumonia - encourage deep breathing - want "good lung" up - drink plenty of fluids - assess for ability to swallow

Types of spinal cord injury

- Hyperflexion - Hyperextension - Vertical compression (e.g. land directly on head) - Rotational forces (e.g. chiropractic)

In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia? 1. High Fowler 2. Left side-lying 3. Right side-lying 4. Flat on the back

1. High Fowler A client experiencing AE would immediately be placed sitting up to lower blood pressure.

Which assessment is the priority after checking airway for a client with a cervical spine injury? 1. Level of consciousness 2. Sensory perception in all extremities 3. Presence and location of diaphoresis 4. Vital sign assessment and oxygen assessment

1. Level of consciousness Airway first, then LOC as part of Glasgow Coma Scale, then sensory perception, then diaphoresis if looking for AE, then vital signs and oxygen.

While caring for a client in traction, which action would the nurse delegate to a licensed practical nurse (LPN)? Select all that apply. 1. Padding traction connections 2. Determining correct body alignment 3. Assessing complications associated with immobility 4. Teaching the client about range-of-motion (ROM) exercises 5. Assisting the client with passive and active range-of-motion exercises

1. Padding traction connections 5. Assisting the client with passive and active range-of-motion exercises

Which education would the nurse provide the parent of a preschool child with a spinal cord injury about foods to avoid during prolonged bed rest to prevent complications associated with immobility? 1. Fish 2. Fruit 3. Beef 4. Cheese

4. Cheese Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification. Protein is needed for wound healing and growth. Fiber decreases the risk of constipation.

T1-T12 spinal nerves (Thoracic)

Motor movement, sensory, abdomen, legs, balance, posture

C1 - C8 spinal nerves (Cervical)

Neck, shoulder, upper arms, diaphragm (patient may need ventilator)

Autonomic Dysreflexia

- It is a MEDICAL EMERGENCY (can lead to stroke or seizure) - Happens if SCI is T6 or higher - Happens when irritating stimulus occurs below the site of spinal injury - Can cause high BP (vasoconstriction below level of injury), flushing (vasodilation above level of injury), low HR (parasympathetic NS response), headache, blurred vision, sweating, goosebumps - Priority action: Sit patient up or raise head of bed to High Fowlers to relieve pressure and lower BP - Other actions: loosen restrictive clothing, check for fecal impaction, urinary retention, and skin integrity - Meds: antihypertensives

Risk for social isolation

- assess the patient's outlook/attitude - address spiritual needs

Interrupted family process

- caregiver burnout - family dynamics change - financial need

decreased cardiac output

- elevate HOB - monitor BNP, lactic acid, electrolytes

Functional ability

- help to preform own ADLs to best of ability - recommend support groups

Risk for infection

- keep halo device clean - aspiration risk (pneumonia) - mouth care - skin care - monitor lactic acid, WBC, blood cultures, RBC, electrolytes

Halo device care

- keep key on device in case of emergency - clean pin sites with normal saline at least once per day (sites should not be red, swollen, or leaking fluid) - don't use halo device to reposition a client - room for flat hand between vest and skin - keep vest clean and dry (no hairspray, lotions, powders) - cut food into small pieces, use straw for drinks - use rolled towel under neck when lying down

Bloating and abdominal distention

- may need to decompress using NG tube - NG tube use may lead to metabolic alkalosis (monitor electrolytes, may need IV nutritional supplements)

Ineffective thermoregulation

- monitor temperature - if they are cold, may be at risk for poor circulation

Risk for constipation

- plenty of fluids - bowel regimen (enema, colace, miralax)

Risk for impaired skin integrity

- turn q2h - good skin care - consider nutrition (albumin) - may have PEG tubes (proper care of sites)

Causes of spinal cord injury

- vehicle crashes - falls - violence - sports - happens more in men

Which statement regarding mealtime administration by a client who has arthritis and is prescribed corticosteroid medication indicates that the teaching was effective? 1. "This will decrease gastric irritation." 2. "This will serve as a reminder to take the medication." 3. "The presence of food will enhance absorption." 4. "The medication is ineffective in an acid medium."

1. "This will decrease gastric irritation." The presence of food limits the irritating effect of steroids on the gastric mucosa.

Which complication would the nurse monitor for in a client on strict bed rest for 3 days? Select all that apply. 1. Atelectasis 2. Hypotension 3. Constipation 4. Pressure injuries 5. Urinary tract infection

1. Atelectasis 2. Hypotension 3. Constipation 4. Pressure injuries 5. Urinary tract infection Clients on bedrest are at risk for complications secondary to immobility, such as atelectasis, hypotension, constipation, pressure injuries, and urinary tract infections.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. 1. Bradycardia 2. Hypotension 3. Spastic paralysis 4. Urinary retention 5. Increased pulse pressure

1. Bradycardia (due to vasodilation below level of injury) 2. Hypotension (loss of vascular tone below the injury) 4. Urinary retention (due to autonomic nervous system dysfunction)

A pediatric client is prescribed an intravenous infusion of methylprednisolone. Which clinical manifestation requires immediate intervention during administration of the initial dose. 1. Polyuria 2. Tinnitus 3. Drowsiness 4. Hypotension

1. Polyuria Intravenous administration of a steroid can cause a rapid increase in the blood glucose level. One early sign of hyperglycemia is increased urine output. Blood glucose should be checked frequently, and insulin administered as needed.

A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which clinical manifestations would the nurse assess? 1. Suprapubic distention 2. Increased spinal reflexes 3. Adventitious breath sounds 4. Imminent development of shock

1. Suprapubic distention Suprapubic distention is a symptom of autonomic dysreflexia, which is commonly precipitated by a distended bladder. Blood pressure increases suddenly with AE causing the severe headache and nasal congestion.

Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia? 1. Assess for the cause. 2. Place the client in sitting position. 3. Check the client for fecal impaction. 4. Give an alpha blocker prophylactically.

2. Place the client in sitting position Clients with autonomic dysreflexia would immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure.

What is the purpose of placing a child in cervical traction after sustaining a fractured cervical vertebra? 1. Hyperextending the neck maintains an open airway 2. Flexing the head prevents stretching of the neck muscles 3. Immobilizing the area minimizes injury to the spinal cord 4. Aligning the body allows for cerebrospinal fluid to encircle the spinal cord

3. Immobilizing the area minimizes injury to the spinal cord The goal is to prevent spinal cord injury; cervical traction immobilizes the area and extends the neck muscles, allowing the vertebrae to separate and thus minimizing spinal cord compression.

L1 - L5 spinal nerves (Lumbar)

lower back, hips, legs, impacts muscle in the thighs and walking

S1 - S5 spinal nerves (Sacral)

lower legs, sexual function, bladder and bowel control

SCI related medications

- Methylprednisolone - steroid, reduces inflammation - fluoxetine - SSRI; helps decrease nightmares and restlessness, promotes sleep - paroxetine - SSRI; helps with depression - pantoprazole - proton pump inhibitor (PPI); prevents stress ulcers - antihypertensives

During the immediate postinjury period, which action is the priority focus of nursing care for a client with a spinal cord injury? 1. Inhibiting urinary tract infections 2. Preventing contractures and atrophy 3. Avoiding flexion or hyperextension of the spine 4. Preparing the client for vocational rehabilitation

3. Avoiding flexion or hyperextension of the spine The priority of care at this time is to protect the spine from additional damage to the traumatized area while it heals.

Which condition would the nurse suspect in an emergency department client with C8 tetraplegia, blood pressure of 80/40 mmHg, pulse of 48 beats per minute, and respiratory rate of 18 breaths per minute? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

3. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin caused by the loss of adrenergic stimulation below the level of the lesion.

Which priority intervention would the nurse perform immediately for a client with a spinal cord injury? 1. Monitor the urinary output. 2. Assess for other injuries. 3. Infuse Lactated Ringer solution. 4. Immobilize and stabilize the cervical spine.

4. Immobilize and stabilize the cervical spine. First, cervical spine should be immobilized and stabilized, then oxygen levels stabilized. The other things can happen after immediate interventions are performed.

Which responses would alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1. Flaccid paralysis and numbness 2. Absence of sweating and pyrexia 3. Escalating tachycardia and shock 4. Paroxysmal hypertension and bradycardia

4. Paroxysmal hypertension and bradycardia An exaggerated response of the autonomic nervous system causes paroxysmal (sudden) hypertension and bradycardia.

Which problem is the nurse trying to prevent by encouraging a client with a spinal cord injury to increase oral fluid intake? 1. Dehydration 2. Skin breakdown 3. Electrolyte imbalances 4. Urinary tract infections

4. Urinary tract infections High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.