Chapter 43: Spinal Cord Injury
Questions to ask after a SCI:
-Location & position of the patient after injury. -Symptoms that occurred immediately with the injury. -Changes that have occurred subsequently -Type of immobilization devices used and whether any problems occurred during stabilization and transport to the hospital. -Treatment given at the scene of injury or in the emergency department -Medical history, including osteoporosis or arthritis of the spine, congenital deformities, cancer, and previous injury or surgery of the neck or back. -History of any respiratory problems, especially if the patient has experienced a cervical SCI
A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. Maintaining a patent airway b. Maintaining immobilization of the cervical spine c. Assessing the patient for head and other injuries d. Assessing the patient's motor and sensory function
A
During the patient's process of grieving for the losses resulting from spinal cord injury, what should the nurse do? a. Help the patient to understand that working through the grief will be a lifelong process. b. Assist the patient to move through all stages of the mourning process to acceptance. c. Let the patient know that anger directed at the staff or the family is not a positive coping mechanism. d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.
A
The home health nurse reads in the patient's chart that he has spinal cord injury and has developed heterotopic ossification of the right hip. What would the nurse expect to observe while assessing the hip? a. Redness, warmth, and decreased ROM b. Obvious deformity, with protrusion of the hip joint c. Pronounced muscle atrophy and wasting of the femur d. Poor skin turgor, with fragility and possible skin tears.
A
The nurse is caring for a patient who is experiencing spinal shock. What are the expected findings that occur with the condition? a. Temporary loss of motor, sensory, reflex and autonomic functions. b. Stridor, garbled speech, or inability to clear airway c. Hypotension and a decreased LOC d. Bradycardia and decreased UO
A
The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention
A
A complete SCI vs Incomplete SCI
A complete damages cord in a way that eliminates all innervation below the level of injury. Incomplete allow some function or movement below the level of the injury.
Hyperflexion
A sudden and forceful acceleration of the head forward causing extreme flexion of the neck. Often the result of a head-on motor vehicle collision or diving accident. Fall on buttocks can also cause the truck to suddenly flex on itself.
A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.
ABE
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (SATA) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation
ACD
When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers
ACDE
A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation
B
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
B
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? a. "It is really still too soon to know if you will have a return of function." b. "That could be a really positive finding. Can you show me the movement?" c. "That's wonderful. We will start exercising your legs more frequently now." d. "I'm sorry but the movement is only a reflex and does not indicate normal function."
B
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)
B
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patients respiratory effort. C. Check the patients level of consciousness. D. Examine the patient for any external bleeding.
B
The nurse is assessing a pt with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. Check for bladder distention b. Raise the head of bed c. Administer an anti-hypertensive med d. Notify the provider
B
The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? A. Dopamine hydrochloride (Inotropin) B. Nifedipine (Procardia) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt)
B
The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? a. Going out in the cold b. Driving c. Sexual activity d. Bathing in the bathtub
B
The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.
B
Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse? a. "You will have more normal function when spinal shock resolves and the reflex arc returns." b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved." c. "When your condition is more stable, MRI will be done to reveal the extent of the cord damage." d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be."
B
When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to a. suction the mouth and oropharynx. b. immobilize the cervical spine. c. administer supplemental oxygen. d. obtain venous access.
B
When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.
B
Which patient behavior is most likely to occur with spinal shock? a. Demonstrates restlessness and is easily agitated b. Displays inability or difficulty moving extremities c. Is disoriented to person, place, and time d. Reports severe pain that radiates down the spine
B
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs
B Neurogenic shock associated with cord injuries above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body.
Which symptoms indicate that a patient with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. a. Flaccid paralysis b. Hypertension c. Tachypnea d. Severe headache e. Blurred vision f. Loss of reflexes below the injury
BDE
A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing.
C
A college student was drinking beer & dove from a 20-foot ledge into a lake. He was from the lake by a friend & given mouth-to-mouth. The patient is currently in the ED, awake, & receiving supplemental oxygen. What serial assessments is the nurse most likely to initiate for this patient? a. Cardiac monitoring for possible myocardial infarction b. Level of consciousness & orientation to monitor for stroke c. Peripheral sensation & movement related to spinal cord injury d. Frequent blood glucose checks to monitor for hypoglycemia
C
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.
C
A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patient's mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.
C
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge? a. Rehabilitation measures cannot be initiated until spinal shock has resolved. b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.
C
During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? a. Institute frequent turning and repositioning. b. Use tracheal suctioning to remove secretions. c. Assess lung sounds and respiratory rate and depth. d. Prepare the patient for endotracheal intubation and mechanical ventilation
C
The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient assessment? a. Heart rate of 68 bpm b. Respiratory rate of 24 c. Blood pressure of 106/82 mm Hg d. Temperature of 96.8°F (36.0°C)
C
The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury
C
The patient with a spinal cord injury has an HR of 42 bpm. Which drug does the nurse expect to administer? a. Methylprednisolone b. Dextran c. Atropine d. Dopamine
C
What causes an initial incomplete spinal cord injury to result in complete cord damage? a. Edematous compression of the cord above the level of the injury b. Continued trauma to the cord resulting from damage to stabilizing ligaments c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury
C
What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? a. Heatstroke b. Paralytic ileus c. Hypertensive stroke d. Aspiration and pneumonia
C
The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes
C With the injury at T4, the highest-level realistic goal for this patient is to be able to be independent in self-care and wheelchair use because arm function will not be affected.
Penetrating trauma
Classified by the speed of the object causing the injury. Low-speed or high-speed.
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential
D
A patient with a spinal cord injury has paraplegia and paraparesis. The nurse assesses the calf area of both legs for swelling, tenderness, redness, or pain. This assessment is specific to the patient's increased risk for which condition? a. Contractures of both joints b. Bone fractures c. Pressure ulcers d. Venous thromboembolism
D
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need? a. IV fluids b. Tube feedings c. Parenteral nutrition d. Nasogastric suctioning
D
The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Begin driving 1 week after discharge." B. "Avoid using a pillow under the head while sleeping." C. "Swimming is recommended to keep active." D. "Keep straws available for drinking fluids."
D
What is one indication for early surgical therapy of the patient with a spinal cord injury? a. There is incomplete cord lesion involvement. b. The ligaments that support the spine are torn. c. A high cervical injury causes loss of respiratory function. d. Evidence of continued compression of the cord is apparent.
D
In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).
D, C, B, A, E
A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, number the following nursing actions in order of priority from highest to lowest (begin with number 1 as first priority). __________ a. Administer ordered prn nifedipine (Procardia). __________ b. Check for bladder distention. __________ c. Document the occurrence, treatment, and response. __________ d. Place call to physician. __________ e. Raise the head of bed (HOB) to 45 degrees or above. __________ f. Loosen tight clothing on the patient.
EBDFAC
Axial loading or vertical compression
Results from diving accidents, falls on buttocks, or jumping and landing on feet. A blow to the top of the head can cause the vertebrae to shatter and pieces of bone to enter the spinal canal and damage the cord.
Excessive Rotation
Results from injuries that are caused by turning the head beyond the normal range.
Hyperextension
The head is suddenly accelerated and then decelerated. Patient's chin is struck. Occurs most often in vehicle collision in which vehicle is struck from behind.
Secondary SCI Injuries
Worsens the primary injury -Hemorrhage -Ischemia -Hypovolemia -Impaired tissue perfusion from neurogenic shock -Local Edema
The nurse is caring for a patient with recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? Select all that apply. a. Frequently perform passive ROM exercises b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program d. Keep the pt immobilized with neck or back braces e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature
bcef
