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NURS 412 Midterm #2 > Nursing Assessment and Interventions for SCI > Flashcards

Nursing Assessment and Interventions for SCI Flashcards

1
Q

Nursing Assessment: Subjective Data (7)

A
  • past health history
  • current medication history
  • symptoms
    loss of strength, movement and sensation below level of injury
    dyspnea “air hunger”
    pain
    fear, denial, anger, depression
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2
Q

Nursing Assessment: Objective Data
- general
- integumentary
- respiratory
- cardiovascular
- GI
- urinary
- reproductive
- neurological
- musculo-skeletal

A

poikilothermism
neurogenic shock
lesions at C1-C3, C4 and C5-T6
lesions above T5
decreased or absent bowel sounds
retention, flaccid bladder
priapism, loss of sexual function
complete, incomplete
atony, contractures

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3
Q

Nursing Diagnoses (7)

A
  • ineffective breathing pattern
  • imbalanced nutrition: less than body requirements
  • ineffective peripheral tissue perfusion
  • impaired skin integrity
  • constipation
  • impaired urinary elimination
  • risk for autonomic dysreflexia
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4
Q

Planning: Overall Goals (4)

A
  1. maintain optimal level of neurological function
  2. have minimal to no complications related to immobility
  3. learn skills and gain knowledge to care for themselves
  4. return home and to the community
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5
Q

Acute Interventions: Immobilization (4)

A
  • proper immobilization involves maintenance of a neutral position
  • Stabilize neck to prevent lateral rotation of cervical spine (blanket or towel, hard cervical collar, backboard)
  • body should always be correctly aligned
  • Turn client so that he or she is moved as a unit to prevent movement of spine (log rolling)
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6
Q

Skeletal Traction (6)

A
  • realignment or reduction of injury
  • provided by rope over a pulley that has weights attached to the end
  • traction must be maintained at all times
  • stabilize head if dislodged, and then call for help
  • sites of pin insertion can become infected
  • Clean twice daily
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7
Q

Cervical Collars

A
  • for postsurgical stabilization are used on the basis of surgeons preference
  • with new techniques and better surgical stabilization, a collar is not required postoperatively
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8
Q

Halo Traction (3)

A
  • the most commonly used method of stabilizing cervical injuries
  • hanging weights may be incorporated
  • may be attached to a body vest that allows ambulation
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9
Q

Immobilization: thoracic or lumbar spine injuries (2)

A
  • custom thoracolumbar orthosis (TLSO brace)
  • meticulous skin care is critical
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10
Q

Acute Interventions: Respiratory Dysfunction

A
  • During first 48 hours, spinal cord edema increases level of dysfunction
  • respiratory distress may occur
  • respiratory arrest is a possibility
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11
Q

Respiratory Dysfunction: injury at or above C3 (4)

A
  • Client is exhausted
  • laboured breathing/ABGs deteriorate
  • endotracheal intubation/tracheostomy
  • mechanical ventilation
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12
Q

Respiratory Dysfunction: other potential problems

A
  • pneumonia and atelectasis
  • nasal stuffiness and bronchospasms
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13
Q

Respiratory Dysfunction: Nursing Interventions (3)

A
  • aggressive chest physiotherapy
  • adequate oxygenation
  • proper pain management
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14
Q

Respiratory Dysfunction: Regularly assess (8)

A
  1. Breathing sounds
  2. Breathing pattern
  3. ABGs
  4. Tidal volume
  5. vital capacity spirometer
  6. skin colour
  7. subjective comments
  8. amount and color of sputum
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15
Q

Cardiovascular Instability: vagal stimulation
- what two things cause vagal stimulation?

A
  • heart rate is slow (<60 beats per min) because of unopposed vagal response
  • any increase in vagal stimulation can result in cardiac arrest. vagal stimulation can happen with:
    1. turning
    2. suctioning
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16
Q

Unopposed vagal response

A

Unopposed vagal response: SPI causes disruption of descendent pathways from central control centers to spinal sympathetic neurons originating in intermediallateral nuclei of T1 to L2 spinal cord segments. Loss of superspinal control over sympathetic nervous system results in reduced overall sympathetic activity below the level of injury

17
Q

Nursing Interventions for Cardiovascular Instability (5)

A
  • Frequently assess vital signs
  • anticholinergic for bradycardia
  • temporary/permanent pacemaker
  • compression gradient stockings (remove q8h for skin care)
  • prophylactic low-molecular-weight heparin
18
Q

Fluid and Nutritional Maintenance (4)

A
  • during first 48-72 hours, GI tract may stop functioning
  • nasogastric tube may be inserted
  • fluid and electrolyte needs must be carefully monitored
  • oral foods and liquids can be given once bowel sounds are present or flatus has passed
19
Q

Fluid and Nutritional Maintenance: Nursing Interventions (3)

A
  • high-protein, high-calorie diet
  • evaluate swallowing in high cervical cord injuries before starting oral feedings
  • if client is not eating, cause should be thoroughly assessed
20
Q

Bladder and Bowel Management: immediately after injury (4)

A
  • urine is retained
  • loss of autonomic and reflex control of bladder and sphincter
  • bladder overdistension can result in reflux into kidney with eventual renal failure
  • intermittent catheterization program (UTI)
21
Q

Bladder and Bowel Management: Constipation (3)

A
  • problem during spinal shock
  • no voluntary or involuntary evacuation of bowels occurs
  • rectal stimulant (suppository or mini-enema) inserted daily
22
Q

Temperature Control (5):
below level of injury (3)

A

Below level of injury:
- vasoconstriction
- piloerection
- heat loss through perspiration
Temperature is largely external to client
Nurse must monitor environment and body temperature

23
Q

Stress Ulcers

A

Physiological response to severe trauma or physiological stress
High-dose corticosteroids
Peak-incidence occurs 6-14 days after injury

24
Q

Sensory Deprivation

A
  • stimulate client above level of injury
  • conversation, strong aromas, music, interesting flavours
  • every effort should be made to prevent client from withdrawing
25
Q

Return of reflexes

A

Return of reflexes may complicated rehabilitation:
- hyperactive
- exaggerated responses
- penile erections
- spasms
Client or family may see this as return of function

26
Q

Autonomic Dysreflexia
what is it?
clinical manifestations (9)

A

The most seriously acute complication of spinal cord injury when injury is above T6
- Severe hypertension (>300 mmHg normal BP in SCI pts is 90-100)
- pounding headache
- flushing
- piloerection
- diaphoresis
- dilated pupils
- nasal stuffiness
- bradycardia
- nausea

27
Q

Most Common Causes of Autonomic Dysreflexia

A
  • most common precipitating factor is distended bladder or rectum
  • can also occur with stimulation of skin or pain receptors (pants too tight)
  • it is important to measure BP when a client with a SCI c/o headache
28
Q

Nursing Interventions for Autonomic Dysreflexia (5)

A
  • elevate HOB at 45 degrees or sit client upright
  • notify physician
  • assess cause
  • provide immediate catheterization
    Teach client and family causes and symptoms
29
Q

Pathophysiology of autonomic dysreflexia

A

Sympathetic reflex arc starts going – gets picked up in the baroreceptors which causes the BP to rise. No parasympathetic system to react and bring the blood pressure back down.
Only treatment is to relieve the causative factor

NURS 412 Midterm #2 (18 decks)

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