Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NSG 410 MS II (mcp) > Unit 2: Assessment + Interventions for Spinal Cord Injuries > Flashcards

Unit 2: Assessment + Interventions for Spinal Cord Injuries Flashcards

1
Q

Patient teaching to prevent Spinal Cord Injuries (SCI)

A
  1. Avoid taking risks (HAHA yeah right)
  2. Use protective measures (helmets, pads)
  3. Wear a seatbelt
  4. Avoid impaired driving
  5. Avoid diving in shallow water (need ~9 feet)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Patient History r/t an acute SCI aims to identify how it occurred and the probable mechanism of injury. Questions include:

A
  1. Location and position immediately after injury
  2. Sxs immediately after injury
  3. Changes that have occurred subsequently
  4. Type of immobilization devices used
  5. Problems that occurred during stabilization and transport
  6. Tx given at the scene of injury or ED
  7. Medical Hx including osteoporosis or arthritis of spine, congenital deformities, cancer, and previous injuries or surgeries of the neck or back.
  8. Hx of respiratory problems (esp. if cervical SCI)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Diagnosis of an SCI (4)

A
  1. Dermatomes
  2. X-ray
  3. Spinal CT
  4. MRI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What two Diagnostic tests can determine the degree and extent of spinal cord damage?

A

CT and MRI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What type of SCI is at the highest risk for respiratory compromise? What about CV compromise?

A

Cervical SCI (C3-C5) → “C3/C4 = breathe no more”
SCI Above T6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

3 Main assessments following an SCI

A
  1. ABCs
  2. Neuro (LOC, Glasgow Coma Scale)
  3. MS + Sensory (Myotomes/Dermatomes, DTRs)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

The Priority assessment following an SCI

A

ABCs! → Respiratory status is first priority
1. Establish airway
2. Assess breathing (RR/pattern/effort)
3. Assess BP + peripheral perfusion (pulses, cap. refill, color, temp) + indications of hemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Why are we assessing Dermatomes/Myotomes?

A

To determine the level of injury for motor and sensory function and establish a baseline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Assessments to perform HOURLY following an acute SCI and findings that require immediate call to Rapid Response

A
  1. SpO2 (<95%)
  2. Sxs of Aspiration (Stridor, garbled speech, inability to clear airway)
  3. Symptomatic Bradycardia (LOC, decreased U/O)
  4. Hypotension (SBP <90 or MAP <65 mm Hg)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

If the pt develops a decrease in sensory perception &/or a new loss of motor function/mobility from baseline, what should you do?

A

Notify provider!
Considered an EMERGENCY!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How often should we, in collaboration with RT, perform a complete respiratory assessment for a pt with a cervical SCI? What should this include?

A

q 8-12 hrs; breath sounds q 2-4 hrs for first few days
Breathing (RR/pattern/effort), SpO2, arterial O2 saturation
Able to breathe independently? Shallow? Able to cough?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Keeping in mind the major causes of death r/t an SCI, an SpO2 of <92% + adventitious breaths sounds may indicate a complication such as

A

Pneumonia or Atelectasis!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

CV Assessment r/t an SCI

A
  1. HR (bradycardia)
  2. ECG (dysrhythmias)
  3. BP (hypotension/orthostatic hypotension)
  4. Temp (hypothermia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A systolic BP of <__ mmHg requires immediate Tx because of lack of perfusion to the spinal cord could worsen the pt’s condition due to _____ to the SCI.

A

A systolic BP of <90 mmHg
Hypoxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Interventions for Bradycardia <50-60 bpm

A

Atropine, Pacing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Interventions for Hypotension

A

IV Vasopressors (Dopamine, etc.)

17
Q

_________ _____ is a complication of spinal trauma and causes a sudden loss of communication within the SNS which maintains normal muscle tone in blood vessel walls. Causes peripheral vasodilation leading to venous pooling + dependent edema in the extremities, a drop in cardiac output, bradycardia, and life-threatening hypotension.

A

Neurogenic Shock

18
Q

Neurogenic Shock Interventions

A

Treated based on Sxs
1. IV fluids for hypotension
2. IV Vasopressors for hypotension
3. BP Meds for bradycardia

19
Q

Respiratory Interventions

A
  1. Maintain SpO2 >95%
  2. Pulmonary hygiene (secretions, suctioning, IS)
  3. Quad cough
  4. Respiratory support (BiPAP, Trach, ventilator)
20
Q

GI/GU Assessment r/t an SCI

A
  1. Assess for Internal bleeding (trauma, ulcer, stress)
  2. Bowel sounds (Paralytic ileus w/in 72 hrs)
  3. Bladder distention (U/O)
21
Q

What assessment findings would we see if the pt developed Autonomic Dysreflexia?

A

S/S of SNS stimulation!
1. Sudden HTN
2. Bradycardia (reflexive)
3. Severe HA (from HTN)
4. Nasal congestion
5. Profuse diaphoresis + Flushing above injury
6. Pale, cold skin + Goosebumps below injury
7. Fever

22
Q

Patients at the greatest risk for developing Autonomic Dysreflexia are those with altered

A

Sensory perception!

23
Q

What’s the biggest risk/complication r/t Autonomic Dysreflexia we should monitor for?

A

Hemorrhagic stroke due to severely elevated BP

24
Q

Prevention of Autonomic Dysreflexia

A
  1. No extreme room temps
  2. No tight fitting
  3. Indwelling catheter
  4. Assess GI for fecal impaction
  5. Meds
    - Stool softeners
    - BP meds (Clonidine)
25
Q

Immediate Interventions for Autonomic Dysreflexia

A
  1. Raise HOB and sit pt UP
  2. Call Rapid Response
  3. Determine the cause (urinary retention, UTI, kidney stones, fecal impaction, pressure injury)
  4. Monitor BP q 10-15 min
  5. Administer Meds to lower BP
    • Nifedipine or Nitroglycerin
26
Q

Spinal Precautions:
What is “BLT”

A

B = bending—Avoid bending spine
L = lifting—Don’t lift more than 5-10 lbs
T = twisting—Don’t twist neck or back

27
Q

Spinal cord Precautions

A
  1. Support head
  2. Firm surface/mattress (no specialty air mattress)
  3. Log Roll
  4. Teach “BLT”
  5. Follow MD orders
28
Q

Spinal cord Precautions
What type of MD orders may we see?

A
  1. Bedrest
  2. HOB orders
  3. Sit limits (time spent sitting, etc.)
  4. Cervical Collar
  5. TLSO Brace/Clamshell
29
Q

Medications for SCI

A
  1. Muscle relaxers (Tizanidine, Cyclobenzaprine, intrathecal baclofen)
  2. Steroids
  3. Pain Mx (gabapentin, lyrica, NSAIDs)
  4. BP Mx
  5. Stool softeners
30
Q

Non-Surgical Tx of SCI

A
  1. Spinal cord stabilization (cervical collar, halo fixator, skeletal traction, log roll)
  2. Aggressive rehab

NSG 410 MS II (mcp) (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions