CS 7 - Spinal Cord Injury Flashcards
Mr. M is a 32-year-old man brought to the emergency department (ED) by paramedics after a fall from the second-story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal radiographs are obtained, the health care provider (HCP) determines that he has a vertebral compression injury at the C4 to C5 level.
- Which questions would the nurse ask the paramedics to obtain a history of the client’s acute spinal cord injury (SCI)? Select all that apply.
- What was the location and position of the client immediately after the injury?
- Did the client experience symptoms before the injury?
- Have any changes occurred since the injury?
- What type of stabilization devices were used to stabilize the client?
- Were any other persons injured at the same time at the client?
- What treatments were given at the injury scene and en route to the ED?
Ans: 1, 3, 4, 6 When obtaining a history from a client with an acute SCI, gather
as much data as possible about how the accident occurred and the probable mechanism of injury after the client is stabilized. Questions asked by the nurse should include:
• Location and position of the client immediately after the injury
• Symptoms that occurred immediately with the injury
• Changes that have occurred since the injury
• Type of immobilization devices used and whether problems occurred during stabilization and transport to the hospital
• Treatment given at the scene of injury or in the ED (e.g., medications, IV fluids)
• Medical history, including osteoporosis or arthritis of the spine, congenital deformities, cancer, and previous injury or surgery of the neck or back
• History of respiratory problems especially if the client has experienced a cervical SCI
Focus: Prioritization.
What is the nurse’s priority concern during admission to the ED?
- Spinal immobilization to prevent additional injuries to the client
- Airway status because of interruption of spinal innervation to the respiratory muscles
- Potential for injuries related to the client’s decreased sensation
- Dysrhythmias caused by disruption of the autonomic nervous system
Ans: 2 The priority at the time of admission to the ED with an SCI at the C4 to C5 level is airway and respiratory status. The cervical spine nerves C3 to C5 innervate the phrenic nerve, which controls the diaphragm. Careful and frequent assessments are necessary, and ET intubation may be required to prevent respiratory arrest. The other three concerns are appropriate but are not urgent like airway and respiratory status. Focus: Prioritization.
The ED nurse assists the ED HCP in testing Mr. M’s deep tendon reflexes (DTRs) which are all absent. What does the nurse suspect is the likely cause of the absent DTRs?
- Spinal shock
- Stabilization devices
- Lack of oxygen to the nerves
- Neurogenic shock
Ans: 1 The HCP tests DTRs, including the biceps (C5), triceps (C7), patella (L3), and ankle (S1). It is not unusual for these reflexes, as well as all mobility or sensory perception, to be absent immediately after the injury because of spinal shock. When spinal shock has resolved, the reflexes may return if the lesion is incomplete. Complete but temporary loss of motor, sensory, reflex, and autonomic function often lasts less than 48 hours but may continue for several weeks. Spinal shock is not the same as neurogenic shock. Neurogenic shock results from hypotension and sometimes occurs with bradycardia. It can be caused by severe damage in the central nervous system, which includes the brain and cervical and thoracic spinal cord. The trauma or injury
brings sudden loss of sympathetic stimulation of the blood vessels, causing
blood vessels to relax and leading to a rapid decrease in blood pressure.
Focus: Prioritization.
Mr. M is stabilized and moved to the neurologic intensive care unit with a diagnosis of SCI at level C4 to C5. As the admitting RN working with an experienced unlicensed assistive personnel (UAP), when frequent respiratory assessments are erformed, which actions can the RN delegate to the UAP?
Select all that apply.
1. Auscultating breath sounds every hour to detect decreased or absent ventilation
2. Ensuring that oxygen is flowing at 5 L/min via the nasal cannula
3. Teaching the client to breathe slowly and deeply and use incentive spirometry
4. Checking the client’s oxygen saturation by pulse oximetry every 2 hours
5. Assessing the client’s chest wall movement during respirations
6. Recording accurate intake and output
Ans: 2, 4, 6 The experienced UAP can make sure that the oxygen flow setting is correct and that the cannula is in place after instructed by the RN. The experienced UAP would also know how to measure oxygen saturation by pulse oximetry. Measuring and recording intake and output is within the scope of practice for a UAP. The nurse retains responsibility for ensuring that the client’s oxygen flow rate is correct and interpreting oxygen saturation measurements. Assessments, including auscultation, and client teaching require additional education, training, and skill and are appropriate to the scope of practice of the RN. Focus: Delegation, Supervision.
An hour later, the UAP informs the RN that Mr. M’s oxygen saturation has dropped to 88%, and his respirations are rapid and shallow at 34 breaths/min. On auscultation, he has decreased breath sounds bilaterally. What is the nurse’s best action at this time?
- Increase the oxygen flow to 10 L/min.
- Suction the client’s airway for oral secretions.
- Notify the HCP immediately.
- Call the respiratory therapist for a nonrebreather mask.
Ans: 3 The nurse should notify the HCP immediately. The client’s symptoms indicate the strong possibility of impending respiratory arrest. This client probably needs ET intubation and mechanical ventilation. Focus: Prioritization.
Which instructions would the RN give the experienced UAP with regard to Mr. M’s care at this time? Select all that apply.
- Check and record vital signs every 15 minutes.
- Use pulse oximetry to check oxygen saturation with each set of vital signs.
- Increase oxygen flow rate by 2 L/min when oxygen saturation is more than 91%.
- Empty the client’s urinary catheter bag and record the output.
- Teach the client how to perform coughing and deep breathing.
- Immediately report decrease in oxygen saturation or increase in respiratory rate.
Ans: 1, 2, 4, 6 Checking vital signs and recording urine output are both within
the UAP’s scope of practice. He or she would also know how to empty the client’s catheter bag. Instructing the UAP to report an increase in respiratory rate or a decrease in oxygen saturation is essential because these findings indicate worsening of the client’s condition. An experienced UAP would also have the skill and knowledge to operate a pulse oximetry device. An oxygen saturation of 91% would be acceptable and would not require increasing the oxygen flow rate. Teaching would require additional skills included within the scope of practice for the professional RN. Focus: Delegation, Supervision.
The HCP prescribes that Mr. M receive endotracheal intubation and be placed on
mechanical ventilation; his oxygen saturation increases to 96%, and respirations decrease to 18 breaths/min (10 ventilator breaths per minute). On auscultation, he has breath sounds present in all lung lobes bilaterally.
7. The nurse is caring for Mr. M when the ventilator’s high-pressure alarm goes
off. What intervention is the client likely to need at this time?
1. Assessment of all ventilator tubing for disconnection
2. Evaluation of the client’s endotracheal (ET) tube for a cuff leak
3. Suction the client for an increased amount of secretions
4. Notification of the respiratory therapist to assess the machine
Ans: 3 The high-pressure ventilator alarm commonly is an indication that the client has increased secretions and needs to be suctioned. The nurse could auscultate for coarse crackles over the trachea because this is also a very common indication that suctioning is needed. Tubing disconnection or cuff air leak would set off the low-pressure alarm. The nurse should assess the
client first and then the machine to discover the problem. If he or she cannot determine the problem, then the RN should manually ventilate the client while the respiratory therapist is notified and determines the problem. Focus: Prioritization.
Mr. M has stabilized and has been weaned off the ventilator. The neurologic intensive care unit nurse is to remove the ET tube. Which actions will the nurse take before removing the tube? Select all that apply.
- Set up an oxygen delivery system.
- Bring emergency equipment for reintubation to the bedside.
- Hyperoxygenate the client.
- Rapidly deflate the ET tube cuff.
- Instruct the client to cough while the tube is removed.
- Administer oxygen by face mask.
Ans: 1, 2, 3, 4 Before extubation (tube removal), oxygen would be set up, emergency equipment would be brought to the bedside, the client would be hyper-oxygenated, and the tube cuff would be deflated. The client would not be asked to cough, and oxygen would not be applied by face mask or nasal cannula until after the tube has been removed. Focus: Prioritization.
The client’s cervical injury has been immobilized with cervical tongs and
traction to realign the vertebrae, facilitate bone healing, and prevent further injury. Which occurrence necessitates the nurse’s immediate intervention?
1. The traction weights are resting on the floor after the client is repositioned.
2. The traction ropes are located within the pulley and are hanging freely.
3. The insertion sites for the cervical tongs are cleaned with hydrogen peroxide.
4. The client is repositioned every 2 hours by using the logrolling technique.
Ans: 1 The traction weights must be hanging freely at all times to maintain the cervical traction and prevent further injury. The other options are appropriate for the care of a client with cervical tongs. Focus: Prioritization;
Test Taking Tip: A question like this is asking the nurse to recognize actions or findings that can be harmful to the client. In this case, when the weights do not hang freely, there is no traction to keep the client’s spine aligned.
Mr. M’s care plan has a nursing concern of impaired mobility. Which actions should the RN delegate to the nursing student providing care for this client on the neurology unit? Select all that apply.
- Administering 50 mg of IV ranitidine in 50 mL of normal saline to prevent gastric ulcers
- Monitoring traction ropes and weights while the client is repositioned
- Assessing the client’s neurologic status for changes in movement and strength
- Providing pin site care using hydrogen peroxide and normal saline
- Adding a nursing concern to the care plan for the client of risk for depression
- Checking vital signs and oxygen saturation
Ans: 1, 4, 6 A nursing student can administer medications and simple treatments such as cervical tong pin care under the supervision of an RN. He or she can also check and record vital signs and oxygen saturation. The nursing student should be mentored by the nurse when monitoring traction during client repositioning and performing neurologic assessments. The nurse should also mentor the student with regard to adding to the client’s care plan because planning care is within the scope of practice for the professional RN. Focus: Delegation, Supervision.
Which action to prevent complications associated with Mr. M’s nursing concern of impaired mobility should the RN delegate to the experienced UAP?
- Assisting with turning and repositioning the client in bed every 2 hours
- Inspecting the client’s skin for reddened areas
- Performing range-of-motion exercises every 8 hours
- Administering enoxaparin subcutaneously every 12 hours
Ans: 1 The experienced UAP has been taught how to reposition clients while
maintaining proper body alignment. The nurse remains responsible for ensuring that this action is performed correctly. Inspecting a client’s skin and administering medications requires additional education and skill and are
appropriately performed by licensed nurses. Performing range-of-motion
exercises also requires additional education and skill and is appropriate to
the scope of practice of licensed nurses and physical therapists. However, some UAPs are given extra training and are able to perform range-of-motion exercises for clients. The skill level and job descriptions of UAP team members should be checked to determine their ability to perform range-of-motion exercises. Focus: Delegation, Supervision.
The nursing student asks the nurse how best to assess Mr. M’s motor function. What is the nurse’s best response?
- “Apply resistance while the client plantar flexes his feet.”
- “Apply resistance while the client lifts his legs from the bed.”
- “Apply downward pressure while the client shrugs his shoulders upward.”
- “Make sure the client is able to grasp objects firmly and form a fist.”
Ans: 3 Mr. M has a level C4 to C5 spinal injury. The best way to assess motor functions in a client with this injury is to apply downward pressure while the client shrugs his shoulders upward. Testing plantar flexion assesses S1-level injuries. Applying resistance when the client lifts the legs assesses injuries at the L2 to L4 level. Having a client grasp and form a fist assesses C8-level injuries. Focus: Prioritization.
The UAP reports that Mr. M’s blood pressure is 178/98 mm Hg; his heart rate
is 50 beats/min; he is sweating around his face, neck, and shoulders; and he reports a severe headache. What does the nurse suspect when assessing this client?
1. Spinal shock
2. Autonomic dysreflexia
3. Neurogenic shock
4. Venous thromboembolism
Ans: 2 Autonomic dysreflexia is a possibly life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in clients with high-level SCI. Symptoms include elevated blood pressure, bradycardia, profuse diaphoresis, flushing, blurred vision, spots in the visual field, and severe
throbbing headache. Focus: Prioritization.
Which actions should the nurse take in caring for Mr. M at this time? Select
all that apply.
1. Place the client in bed in the prone position.
2. Notify the HCP.
3. Check the client’s bladder for urinary retention.
4. Place an incontinence pad on the client.
5. For bladder distention, catheterize the client.
6. Monitor blood pressure and heart rate every 10 to 15 minutes.
Ans: 2, 3, 5, 6 The client’s symptoms indicate the possibility of autonomic
dysreflexia, which can be life threatening. Immediate interventions for this client include placing in a sitting position or previous safe position, notifying the HCP, checking for urinary retention, and catheterization if the client does not already have a catheter. The nurse would check an indwelling catheter’s tubing for kinks or obstruction. Vital signs should be checked at least every 10 to 15 minutes. Other actions that could be taken include checking for fecal impaction or worsening of an existing pressure ulcer. If the HCP prescribes
drugs, nifedipine or a nitrate may be administered. An incontinence pad is
not necessary at this time. Focus: Prioritization.
Mr. M’s condition has stabilized. His cervical injury is now immobilized with a halo fixation device with jacket. He has regained the use of his arms and partial movement in his legs. Which instruction should the nurse give the UAP providing help to Mr. M in activities of daily living?
- “Feed, bathe, and dress the client so that he does not become fatigued.”
- “Encourage the client to perform all of his own self-care.”
- “Allow the client to do what he can and then assist with what he can’t.”
- “Let the client’s wife do the bathing and dressing.”
Ans: 3 The client should be encouraged to perform as much self-care as he is able to do, and the UAP should help with care the client is unable to complete. The client’s wife should also be taught to encourage the client to do as much as possible for himself. Focus: Prioritization, Delegation,
Supervision
