chapter 29
A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
Bradycardia and hypertension
Depressed
Broken bone pushed inward toward the brain
A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
Care of the cervical collar
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? q
Raise the head of the bed and place the patient in a sitting position.
Poikilothermia (cool to touch)
The 6th P when considering patients with PAD
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
epidural hematoma (EDH)
Bleeding between the dura mater and the cranium
Comminuted
Bone splintered into fragments
Contusion (bruise)
results in bruising and, sometimes, hemorrhage of superficial cerebral tissue.
rhinorrhea
runny nose CSF
tentorium
separates the cerebrum from the cerebellum, horizontal plane
cranioplasty
surgical repair of the skull
Trephining
surgically removing circular sections (of bone, for example)
dysreflexia
syndrome in which there is a sudden onset of excessively high blood pressure
autoregulation
the ability of tissues to regulate their own blood supply
craniectomy
the surgical removal of a portion of the skull
intermittent spasticity
uncontrolled jerking movements, muscle stiffness and rigidity
Subdural Hematoma (SDH)
venous bleeding, with blood gradually accumulating in the space below the dura.
supratentorial
(incision behind hairline on forhead) e
antegrade amnesia
(partial or complete inability to recall the recent past; memories from before the traumatic event remain intact)
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?
Check the client's indwelling urinary catheter for kinks to ensure patency.
A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention?
Emergency craniotomy
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
Epidural
Functional Electrical Stimulation (FES)
Form of electrotherapy to: maintain muscle mass gain range of motion facilitate voluntary movement manage spasticity Recommended for use as an adjunct to other occupation-based interventions
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?
Have the client lie on the back and lift the leg, keeping it straight.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
Chemonucleolysis
Injection of an enzyme to dissolve the gelatinous cushioning material in an intervertebral disc.
Simple
Linear crack without any displacement of the pieces
A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?
Place the client in a sitting position.
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.
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply.
Slurred speech Vomiting Weakness on one side of the body
The nurse is assessing a client with a confirmed spinal cord tumor. The client states, "I've been too embarrassed to tell anyone but, I have been awakened at night because I've wet the bed." It would be a priority for the nurse to further assess the client for which complication?
Spinal cord compression
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.
Young age Male gender Substance abuse
spinal shock
a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is:
a result of venous bleeding into the space below the dura.
intracerebral hematoma
bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm
cerebral hematoma
bleeding within the skull
infratentorial
below the tentorium
Battle's sign
can be present
A client had a long and successful ice hockey career but has been forced to retire due to symptoms of depression, memory loss, and difficulty with gait and balance. The neurologist believes the most likely cause of these symptoms is:
chronic traumatic encephalopathy.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
client maintains mechanical ventilation with minimal mucus accumulation
laminectomy
removal of the posterior arch of a vertebra to expose the spinal cord. The surgeon can remove whatever lesion is causing compression: a herniated disk, tumor, blood clot, bone spur, or broken bone fragment.
Diskectomy
removal of the ruptured disk
concussion
results from a blow to the head that jars the brain.
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to:
decrease the potential for brain damage.
otorrhea
discharge from the ear
Autonomic dysreflexia
exaggerated sympathetic nervous system response in people with spinal cord injuries above T6.
Chronic Traumatic Encephalopathy (CTE)
form of dementia caused by repeated head trauma such as concussions
craniotomy
incision of the skull
There are two basic types of spinal nerve root compression:
intramedullary and extramedullary
Intramedullary lesions
involve the spinal cord
extramedullary lesions
involve the tissues surrounding the spinal cord.
Autonomic Dysreflexia
involves uncontrolled activation of autonomic neurons
After undergoing surgery for removal of a spinal cord tumor, the client is placed in the side-lying position. The nurse places a pillow between the client's knees to prevent:
knee flexion.
Contusion (bruise)
more serious than a concussion and leads to gross structural injury to the brain.
Paresthesia
numbness and tingling because of sensory nerve changes
contrecoup injury
occurring on the opposite side; an injury to the brain opposite the site of impact.
Paraplegia
paralysis from the waist down
Tetraplegia (quadriplegia)
paralysis of all four limbs
periorbital ecchymosis
raccoon eyes
DISKECTOMY WITH SPINAL FUSION
•—removal of the ruptured disk followed by grafting a piece of bone taken from another area, such as the iliac crest, onto the vertebra to fuse the vertebral spinous process. Bone also may be obtained from a bone bank
