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NURS 3512 - Class 7-12 > Week 7 - Spinal Cord Injury > Flashcards

Week 7 - Spinal Cord Injury Flashcards

1
Q

what is a spinal cord injury

A
  • an injury to the vertebra that affects the spinal cord
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2
Q

who do SCIs commonly affect

A
  • most freq in young people between ages 15-25

- male to female ratio = 4:1

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3
Q

what is tetraplegia

A
  • paralysis of both arms, leg, and the trunk
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4
Q

an injury to ___ causes tetraplegia

A
  • above C8
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5
Q

what are the most common causes of premature death in an individual w tetraplegia related to (3)

A
  • compromised resp function (penumonia)
  • impaired renal function (UTI)
  • impaired skin integrity (ulcers)
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6
Q

what are common causes of SCI (6)

A
  • motor vehicle accidents
  • sports injuries
  • trauma
  • medical conditions
  • violence
  • falls
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7
Q

SCI occurs d/t (2)

A
  • cord compression by bone displacement, tumour, or abscesses
  • interruption of blood flow to the cord
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8
Q

what is paraplegia

A
  • paralysis of the legs
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9
Q

an injury to which part of the spinal cord causes paraplefia

A
  • below T1
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10
Q

an injury to L1 and lower causez?

A
  • paraplegia

- better trunk control

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11
Q

the pathophys of SCIs is best describe as ??

A
  • biphasic

= the initial mechanical injury (primary injury) is followed by a second phase (secondary injury)

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12
Q

the primary injury includes

A
  • initial mechanical injury w failure of the spinal column (fracture or dislocation) imparts force to the spinal cord
    = disrupted axons, blood vessels, and cell membranes
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13
Q

the secondary injury involves (8)

A
  • ongoing, progressive damage that occurs after the initial injury
  • vascular dysfunction
  • edema
  • ischemia
  • electrolyte shifts
  • inflammation
  • free radical production
  • apoptic cell death
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14
Q

what is the goal in care for SCIs? how is this done (2)?

A
  • limit further cord damage/extension of injury
    1. immobilize
    2. methylprednisone
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15
Q

how is methylprednisone given for an acute SCI? why is it given?

A
  • bolus followed by infusion

- purpose: minimizes secondary injury by reducing inflammation

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16
Q

what is immobilization

A
  • involves the maintenance of a neutral position
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17
Q

how can pts experiencing SCI by immobilized? (4)

A
  • blanket or rolled towel
  • aspen collar
  • backboard
  • cervical traction –> halo traction
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18
Q

describe how a pt with an SCI should be aligned and turned

A
  • correctly aligned
  • moved as a unit to prevent movement of spine
    ex. log rolling
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19
Q

when is cervical traction used (2)

A
  • for cervical injuries

- only when the pt can communicate changes in clinical status during application and subsequent assessment

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20
Q

what is the goal of cervical traction

A
  • realignment or reduction of the injury
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21
Q

what does halo traction involve

A
  • placement of a halo ring or crown that is secured into the skull with four pins
  • includes subsequent additions of weight to aid in spinal realignment
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22
Q

how is traction provided w halo traction

A
  • by a rope that is extended from the center of the halo crown over a pulley and has weights attached to the end
  • must be maintained at all times!
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23
Q

once proper alignment has occur w halo traction, what happens

A
  • a halo vest is applied to provide ongoing immbolization of the cervical spine
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24
Q

what is the benefit of halo vest

A
  • stabilizes the injured area

- allows ambulation of the pt if they are neurologically intact

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25
Q

why is special care imp for the halo vest and halo traction (2)

A
  • prevent skin breakdown

- prevent infection

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26
Q

what is included in nursing care to prveet infection at the pin sites of halo traction (2)

A
  • clean the sites twice a day w NS

- assess for development of redness or crusting

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27
Q

what is included in nursing care to prevent skin breakdown r/t the halo vest and halo traction (5)

A
  • use of special beds to provide kinetic therapy
  • meticulous skin care
  • remove from backboards asap to prevent coccygeal and occipital area skin breakdown
  • properly fit and replace cervical collars
  • assess areas under the halo vest, braces, and orthoses regularly
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28
Q

decsribe how the use of special beds can provide kinetic therapy

A
  • involves continual side-to-side slow rotation, with the pt in constant motion
  • turns more than 200 times per day
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29
Q

what is a con to kinetic therapy (2)

A
  • can cause motion sickness

- risk of pt falling out of bed

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30
Q

what should be done if crusting is present on pin sites (3)

A
  • increase freq of cleaning pin sites to 3x/day
  • wrap the pin site w NS soaked gauze for 15-20 min and then remove
  • using a gentle rolling motion, the crust can then be removed w a cotton-tipped applicator that has been soaked in NS
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31
Q

describe how to provide skin care to a pt with halo vest (6)

A
  • have pt lie down on a bed on their side
  • loosen one side of vest, place towel against the sheepskin to protect it from getting wet
  • assess skin for redness and signs of skin breakdown
  • dry skin thoroughly, and resecure buckle straps
  • do not use lotions or powders under vest
  • turn pt to opposite side and repeat the steps
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32
Q

in case of emergency, what should be done r/t halo vest

A
  • keep a wrench taped to the halo vest at all times
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33
Q

what is the difference between a complete and incomplete spinal cord lesions

A
  • complete = no motor or sensory function below the lvl of injury
  • incomplete = some motor and sensory function preserved below lvl of injury
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34
Q

manifestations of SCIs are r/t?

A
  • lvl (where on the spinal cord?) and degree of injury (complete or incomplete?
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35
Q

what does immediate post injury care for SCIs include (5)

A
  • maintain patency of airway
  • adequate ventilation
  • adequate circulating blood vol & blood pressure to minimize extension of spinal cord damage
  • immobilization
  • methylprednisone
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36
Q

describe resp complications r/t SCIs

A
  • closely relate to lvl of injury
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37
Q

describe the impact of an SCI to C1-C3 (above C4) on the resp system (3)

A

= total loss of resp muscle function

  • often fatal
  • mechanical ventilation required to keep pt alive
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38
Q

describe the impact of an SCI from C4-T6 on resp function (6)

A
  • may breathe spontaneously
  • may have resp insufficiency
  • may have poor cough
  • take small breaths
  • hypoventilation w diaphragmatic breathing
  • decreased vital capacity and tidal volume
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39
Q

SCI to what part of the spinal cord impacts the pt’s ability to cough? how? what does this increase the risk of

A
  • cervical and thoracic injuries
  • cause paralysis of abdominal muscles and often intercosta muscles = cannot cough effectively
    = risk of atelectasis and pneumonia
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40
Q

what impact does a SCI to below T6 have on the resp system

A
  • no resp effects
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41
Q

describe the impact of SCIs on resp function during the first 48 hrs

A
  • spinal cord edema increases = resp distress may occur
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42
Q

describe what is included in nursing care & mngmt of resp effects of SCIs (14)

A
  • ensure airway
  • chest physio
  • adequate oxygenation
  • pain mngmt
  • regular assessments
  • assess ABGs
  • DB&C
  • assistive coughing
  • tracheal suctioning if crackles or wheezing
  • incentive spirometry
  • intubation & mechanical ventilation
  • assess tidal volume, vital capacity
  • assess breathing patterns (esp use of accessory muscles)
  • assess color and amt of sputum
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43
Q

describe assisted coughing

A
  • stimulates action of the ineffective abdominal muscles during the expiratory phase of a cough
  • nurse places heels of both hands below pts xiphoid process and exerts firm upwards pressure to the area
  • should be timed w pts efforts to cough
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44
Q

what may indicate need for intubation or mechnical ventilation (3)

A
  • if injury at or above C3
  • if pt is exhuasted from labored breathing
  • if ABG lvls deteriorate
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45
Q

what may indicate that a pt w an SCI requires immediate attention r/t the resp system

A
  • if they cannot count to 10 out loud without taking a breathing
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46
Q

what are resp risks associated w SCIs(3)

A
  • resp arrest
  • pneumonia
  • atelectasis
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47
Q

what type of SCI has a signif impact on the CVS

A
  • any cord injury above lvl of T6
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48
Q

describe the impact of an SCI above T6 on CVS (5)

A
  • decreases the influence of the SNS

= bradycardia, hypotension (d/t peripheral vasodilation), hypovolemia, decreased CO

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49
Q

d/t its impact on CVS, a SCI to above T6 requires? (3)

A
  • cardiac monitoring
  • if bradycardia <40 beats/min, atropine used to increase HR
  • may require IV fluids or vasopressor drugs to support BP
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50
Q

what is included in nursing care/mngmt of a pt with SCI r/t the CVS (6)

A
  • anticipate shock r/t decreased CO & possible hemorrhage from other injuries
  • assess VS frequently
  • anticholinergic (ex. atropine) for symptomatic bradycardia
  • vasopressors for hypotension (ex. dopamine, NE)
  • fluid replacement
  • temp pacemaker
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51
Q

what are risks associated w the CVS impact of SCIs (3)

A
  • postural hypotension (d/t loss of sympathetic tone)
  • risk of DVT (d/t lack of muscle tone to aid venous return = sluggish blood flow)
  • cardiac arrest
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52
Q

what can increase the risk of cardiac arrest r/t SCIs

A
  • any increase in vagal stimulation

ex. turning and suctioning

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53
Q

what is included in nursing care r/t to the risk of DVTs w SCIs (4)

A
  • DVT prophylaxis
  • sequential compression devices
  • admin of LMWH within 72 hrs of injury
  • ROM and stretching
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54
Q

describe nursing care r/t SCD

A
  • stockings should be remoevd q8h for skin care and assessment
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55
Q

at what point should LMWH be withheld

A
  • morning of surgery

- continue within 24 hr postop

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56
Q

what can cause urinary retention r/t SCIs? (3)

A
  • SCI to T1-L2
  • acute SCI –> immediately after injury
  • spinal shock
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57
Q

after the acute phase, what impact do SCIs have on the bladder

A
  • becomes hyperirritable with a loss of inhibition from the bain = reflex emptying
58
Q

what is included in nursing care for urinary retention (6)

A
  • encourage toilet routines
  • indwelling urinary cath asap during acute phase
  • once pt hemodynamically and medically stable & large quantities of IV fluids not required, intermittent cath
  • fluid restriction of 1800-2000 mL/day
  • monitor urine output
  • bladder training program
59
Q

what is included in nursing care r/t insertion of an indwelling cath (2)

A
  • ensure patency thru inspection and irrigation

- strict aspectic technique for insertion

60
Q

describe nursing care to prevent UTIs in pts with SCI (4)

A
  • best method = complete and regular bladder drainage
  • cath to prevent bladder vol from exceeding 500 mL
  • cranberry juice and cranberry extract tablets
  • urine specimen is signs of UTI
61
Q

what are risks associated w urinary retention (2)

A
  • overdistension = reflux into kidneys = renal failure

- rupture of bladder

62
Q

what is neurogenic bladder? when does it occur?

A
  • any type of bladder dysfunction r/t abnormal or absent bladder innervation
  • occurs after spinal shock
  • includes both urgency, frequency, inability to void, high bladder pressure
63
Q

what are the types of neurogenic bladder (3)

A
  • reflexic = incont, freq, urgency, unpredictable
  • areflexic = bladder distension, hesitancy, overflow incont
  • sensory = lack of sensation to urinate = poor bladder sensation, infreq voiding of large residual vol
64
Q

what meds can be used to treat reflexic bladder (3)

A
  • anticholinergics (suppress bladder contractions, for reflexic)
  • alpha adrenergic blockers (decrease outflow resistance, relax urethral sphincter)
  • antispasmodics (suppress pelvic floor spasticity)
65
Q

an SCI to what lvl of the spinal cord impacts the GI system

A
  • above T5
66
Q

describe an SCI to above T5’s impact on the GI system (3)

A

= hypomotility, paralytic ileus, gastric distension, constipation

67
Q

when and why is constipation generally a problem

A
  • during spinal shock bc no voluntary or involuntary exacuation of the bowel
68
Q

what is included in nursing care for the risk of constipation w SCIs (8)

A
  • NG tube for intermittent suctioning
  • metoclopramide or maxoran (encourage gastric emptying)
  • H2RB, PPIs in the intial phase
  • suppositories
  • disimpaction
  • stool softeners
  • bowel program
  • monitor for abdominal distension, LBM
  • high fibre & fluids
69
Q

why are H2RBs and PPIs administered during the initial phase of SCIs

A
  • the development of stress ulcers is common d/t excessive release of HCl in the stomach in response to severe trauma, stress, and high-dose corticosteroids
    = prevention
70
Q

loss of nuerological control over the bowel results in..

A
  • neurogenic bowel
71
Q

when does neurogenic bowel occur

A
  • occurs in the early period after injury when spinal shock is present
  • injury lvl of T12 or below
72
Q

describe neurogenic bowel

A
  • in the early period, bowel is areflexic & sphincter tone decreased
  • as reflexes return, bowel becomes reflexic & bowel tone is enhance = reflex emptying
  • includes both constipation & incont.*
73
Q

how can neurogenic bowel be managed

A
  • regular bowel program coordinated w gastrocolic reflex to minimize incontinence
74
Q

what impact do SCIs have on the integ system

A
  • lack of movement = potential for skin breadown over bony prominences, esp. in area w no or decreased sensation
  • r/o pressure ulcers which can lead to major infection or sepsis
75
Q

what impact do SCIs have on thermoregulation (3)

A

= poikilothermism, the adjustment of the body temp to room temp

  • decreased ability to sweat or shiver below lvl of injury = impacts the ability to regulate body temp
  • temp control is largely external to the pt
76
Q

why does poikilothermism occur w SCIs

A
  • occur d/t the interruption of the SNS = prevents peripheral temp sensations from reaching the hypothalamus
77
Q

the degree of poikilothermism depends on? how?

A
  • the lvl of injury

ex. pts w cervical injuries have a greater loss of ability to regulate temp than those w thoracic or lumbar

78
Q

what is included in nursing care r/t the temp control impact SCIs have (4)

A
  • monitor the enviro closely to maintain an approp temp
  • regularly monitor body temp
  • do not overload the pt with covers or duly exposured (such as during bathing)
  • if pt gets an infection & fever, may have to use cooling blankets
79
Q

how can SCIs impact metabolic needs (2)

A
  • NG suctioning can lead to metabolic alkalosis, impact electrolytes
  • decreased tissue perfusion can lead to acidosis
80
Q

describe the nursing care for the metabolic impacts of SCIs

A
  • monitor electrolytes until suctioning is d/c
81
Q

what impact do SCIs have on peripheral vascular problems

A
  • r/o DVT & PE during first 3 months
82
Q

what are diagnostic studies used for SCIs (5)

A
  • xray –> assess vertebral fracture
  • mri –> image neurological issues
  • CT –> extent of bone injury & degree of spinal cord compromise
  • comprehensive neuro exam
  • assess head, chest, abdomen
83
Q

what are the initial goals for a pt with an SCI (3)

A
  • sustain life
  • prevent further cord damage
  • treat systemic and neurogenic shock to maintain BP
84
Q

for an SCI at the cervical lvl, what is included in treatment/care?

A
  • all body systems must be maintained until full extent of damage is evaluated
85
Q

what interventions are included in initial management of SCIs (7)

A
  • ensure patent airway
  • stabilize cervical spine w hard collar / sand bags
  • admin O2 via nasal cannula or nonrebreathing mask
  • establish IV access w 2 large bore catheters to admin NS or LR
  • assess for other injuries
  • control external bleeding
  • insert foley
86
Q

what is included in ongoing monitoring of SCIs (7)

A
  • VS
  • LOC
  • O2 sat
  • cardiac rhythm
  • urine output
  • keep pt warm
  • anticipate need for intubation if gag reflex absent or resp function declines
87
Q

what is included in acute care for a cervical cord injury (10)

A
  • maintenance of heart rate & BP (aropine, doapmine)
  • high dose methylprednisone
  • NG tube & suction
  • intubation if indicated
  • admin of O2
  • insert indwelling cath
  • placement of halo traction if necessary
  • prophylaxis for DVTs
  • bowel and bladder training
  • pressure/relieving surface
88
Q

to prevent further injury, how should pts w an SCI be moved and aligned

A
  • should be correctly aligned

- turned and moved as a unit –> thru log rolling

89
Q

describe the diet of a pt with SCI (3)

A
  • high protein
  • high cal
  • high fibre
90
Q

what should be assessed before oral feedings are started

A
  • swallowing

* oral route is optimal for pts with SCI*

91
Q

describe the impact of SCIs on nutrition (2)

A
  • during first 48-72 hr, get paralytic ileus = NG tube

- once bowel sounds are present or flatus has passed, oral food and fluids can be gradually introduced

92
Q

why is a high protein & cal diet imp for a pt with SCI (3)

A
  • have increased metabolic rate during acute phase
  • imp for energy and tissue repear
  • prevent skin breakdown and muscle wasting
93
Q

what should be monitored r/t nutrition for a pt w SCI (2)

A
  • fluid and electrolytes

- metabolic demands to avoid overfeeding

94
Q

what should be done to prevent sensory deprivation in a pt w an SCI

A
  • compensate for absence of sensations by stimulating the pt above the lvl of injury
95
Q

what are some examples of ways to avoid sensory deprivation (5)

A
  • conversation
  • music
  • strong aromas
  • interesting flavours
  • prism glasses for reading & TV
96
Q

describe the impact of SCIs on reflexes

A
  • once spinal shock has resolves, reflexes are hyperactive and responses may be exaggerated
97
Q

what are some examples of how reflexes are hyperactive (3)

A
  • penile erections may result from a variety of stimuli
  • mild twitches or convulsive movements below lvl of lesion
  • neurogenic bladder & bowel
98
Q

how can hyperactive reflexes be mnged

A
  • antispasmodic drugs
99
Q

what are 4 examples of antispasmodic drugs

A
  • baclofen
  • dantrolene
  • tizanidine
  • botulism toxin injections
100
Q

what is included in nursing care r/t the skin for a pt with an SCI (8)

A
  • inspection 2x/day (esp over bony prominences)
  • keep clean and dry
  • skin care
  • turn q2h
  • use of special mattresses or roho cushion
  • assess nutritional status (adequate protein imp.)
  • avoid friction, shear, and abrasion
  • avoid thermal injury
101
Q

describe the impact of SCIs on sexuality (3)

A
  • dysfunction depends on lvl of injury
  • may impact sensation (esp males)
  • may impact fertility (males) –> may be able to retrive sperm for later or may not
102
Q

describe the impact of SCIs on emotional and mental health

A
  • may experience grief, loss, and depression
103
Q

what is included in nursing care r/t the emotional and mental impacts of SCIs (5)

A
  • goal is adjustment
  • support pt & family
  • identify friends and forms of support
  • community resources
  • help them transition thru stages of grief
104
Q

what should you discuss w the pt & family regarding the rehab process

A
  • expectations regarding recovery
  • can be a long or short process
  • can be in or out patient
105
Q

what is the focus of the rehab process for SCIs (2)

A
  • retrain body systems

- long term mngmt of any permanent changes

106
Q

what is spinal shock

A
  • a temporary neurological condition that occurs at the time of injury
  • can lasts days to months, resolves spontaneously
107
Q

what is spinal shock characterized by (4)

A
  • decreased reflexes
  • loss of sensation
  • flaccid paralysis
  • NO changes to VS

all neural activity below or at the lvl of injury ceases

108
Q

what is a con to spinal shock

A
  • may mask secondary signs
109
Q

what is neurogenic shock

A
  • medical emergency

- caused by loss of vasomotor tone as a result of SCI at T5 or above (slides say T5 but I think it’s also for above T6)

110
Q

when does neurogenic shock occur

A
  • can occur up to 6 weeks post-injury
111
Q

why does neurogenic shock occur

A
  • d/t impairment in SNS
    = peripheral vasodilation
    = venous pooling
    = decreased CO
112
Q

what are signs of neurogenic shock (3)

A
  • hypotension (massive dilation)
  • bradycardia (d/t unopposed SNS)
  • warm & dry extremities (venous pooling d/t decreased CO)
113
Q

what is included in treatment of neurogenic shoick (3)

A
  • fluid resus (hypotension)
  • vasopressors (hypotension)
  • atropine (bradycardia)
114
Q

what is autonomic dysreflexia (AD)

A
  • massive, uncompensated CVS reaction mediated by the SNS
  • return of reflexes after the resolution of spinal shock
  • medical emergency that required immediate resolution
115
Q

with what lvl of injury does AD occur

A
  • SCI at T6 or higher
116
Q

what can cause AD

A
  • occurs d/t an irritating simuli below the lvl of injury = exaggerated SNS response
117
Q

what 4 main causes of AD

A
  • bladder distension
  • bowel /rectum distension
  • breakdown of skin
  • stimulation of pain receptors
118
Q

the SNS in response to stimuli in AD causes (3)

A
  • reflex vasoconstriction below the injury (the impulse cant pass thru)
  • bradycardia (in response to vasoconstriction)
  • vasodilation above injury (impulse from the brain blocked to stop vasoconstriction)
119
Q

what are symptoms of AD (9)

A
  • HTN
  • throbbing headache
  • diaphoresis or flushing of skin above injury
  • bradycardia
  • piloerection (raising of body hair)
  • blurred vision or spots in visual field
  • nasal congestion
  • nausea
  • anxiety
  • , pale, cool, clammy below injury
120
Q

what are nursing interventions for AD (5)

A
  • raise HOB to 45 degrees or sit pt upright (cause blood to pool in lower extremities)
  • notify physician
  • determine and remove cause (ex. if it is pain, treat the pain)
  • VS
  • nifodipine (ca channel blocker for HTN)
121
Q

if the cause of AD is bladder distension, what should be done

A
  • immediate cath
122
Q

what should be instilled in the urethra before cath for treatment of AD? why?

A
  • lidocaine gel

- prevent further stimulation

123
Q

if the cause of AD is fecal impaction, what should be done (4)

A
  • digital rectal exam
  • disimpaction
  • stool softener
  • enema
124
Q

a digital rectal exam for AD should only be done after..

A
  • application of an anaesthetic ointment to decrease rectal stimulation and prevent increase in symptoms
125
Q

if neither bladder or bowel is the cause of AD, what should be done

A
  • removal of all skin stimuli

ex. constrictive clothing, tight shoes, splints

126
Q

if symptoms persist after the cause of AD has been removed, what should be done

A
  • admin of alpha adrenergic blockers

- or arterial vasodilator

127
Q

what is an example of an arteriolar vasodilator

A
  • nifedipine
128
Q

if a pt with SCI is complaining of a HA, what is the priority

A
  • check BP
129
Q

prevention of AD is key. what measures can be taken to prevent it (5)

A
  • bowel regime
  • local anasthetics for invasive procedures (ex. manual rectal stimulation)
  • close monitoring of ins and outs (for signs of urinary rention)
  • maintain regular bowel and bladder function
  • wear a medical bracelet indicating history of AD
130
Q

if resolution of AD does not occur, what could happen (4)

A

can lead to

  • status epilectusus
  • stroke
  • MI
  • death
131
Q

what are some meds used for SCI mngmt (3)

A
  • methylprednisone (reduce inflam, aggressive in first 8 hrs of injury)
  • dopamine (increase perfusion)
  • atropine (increase perfusion)
132
Q

what is the goal of surgery for SCI

A
  • stabilize and realign the spinal column
133
Q

what is an examples of surgeries done for SCIs

A
  • laminectomy w fusion
134
Q

what is included in nonsurgical mngmt of SCIs (5)

A
  • alignment
  • stabilization
  • traction
  • physio (strengthening, stretching, balance)
  • mobility aids (braces, canes, wheelchairs)
135
Q

what is a laminectomy

A
  • removal of lamina (back part of vertebra) to increase intervertebral space = decomp. surgery
  • enlarges spinal canal w intention of relieving P on spinal cord or nerves
136
Q

what is a lami & fusion

A
  • use of metal implants (rods, hooks, wires, plates, and screws) secured to vertebra to hold them together until new bone can grow between them
  • may be there forever or revised over time
137
Q

what impact does a lami & fusion have on the vertebra

A
  • the vertebra wont turn the same way anymore

ex. cervical fusion = effect mobility & ROM of neck

138
Q

a nursing diagnosis rt SCIs is ineffective breathing pattern. what nursing interventions can be done for this (7)

A
  • resp monitoring
  • monitor for diaphragmatic muscle fatigue
  • auscultate
  • note changes in SaO2, ABGs
  • monitor ability to cough
  • identify and assess if pt needs actual or potential airway insertion
  • perform endotracheal or nasotracheal suctioning
139
Q

a nursing diagnosis r/t SCIs is impaired skin integirty. what are nursing interventions for this (7)

A
  • monitor for sources of pressure & friction
  • monitor for infection at pin sites, open tong sites
  • ensure approp wound care techniques
  • monitor skin for signs of breakdown
  • use of an approp therapeutic mattress & deviced to relieve pressure
  • turn q2h
  • monitor pts nutritional status
140
Q

a nursing diagnosis r.t SCI is constipation. what nursing interventions can be done for this (4)

A
  • monitor BM
  • monitor BS
  • instruct pt on high fibre and fluid intake
  • initiate bowel training program
141
Q

a nursing diagnosis r/t SCIs is impaired urinary elimination. what nursing interventions can be done for this (5)

A
  • monitor I&O
  • monitor degree of bladder distension w palpation, percussion, bladder scanner
  • insert cath
  • implement intermittent cath in postacute phase
  • refer to urinary continence specialist
142
Q

a nursing diagnosis r.t SCI is risk of AD. what nursing interventions can be done for this (7)

A
  • identify and minimize stimuli that may cause
  • monitor for S&S
  • investigate and remove cause
  • place of HOB in upright position (to reduce BP and promote cerebral venous return)
  • stay w pt and monitor q3-5 min
  • admin antihypertensives IV
  • educate pt & fam on causes, symptoms, treatment, prevention

NURS 3512 - Class 7-12 (49 decks)

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