Part 2: The unstable spinal cord injury

NUR 433: Adult Health II; MCUSON; Mrs. Cooper

***the secondary unstable spinal cord injury is the window nurses control

within seconds of an unstable spinal cord injury, there will be _____ in gray matter and axon damage

hemorrhage

within minutes-hours of an unstable spinal cord injury, inflammation, edema, ischemia, free radicals, and a _____ influx occur

Ca2+

within <24 hours of an unstable spinal cord injury, there will be _____ damage from edema

permanent

within 72 hours of an unstable spinal cord injury, _____ peaks and can ascend levels

edema

within weeks of an unstable spinal cord injury, _____ demyelination, and glial scar occur

apoptosis

the nurse protects the unstable spinal cord with: SpO2 > ___

92%

the nurse protects the unstable spinal cord with: MAP ___-___

85-90

the nurse protects the unstable spinal cord with: spinal motion _____

restriction

the nurse protects the unstable spinal cord with: _____

normothermia

***the spinal cord level predicts the spinal cord problem

with a C4 injury: _____ results in complete paralysis below the neck

tetraplegia

a C6 injury results in partial _____ of hands and arms as well as lower body

paralysis

with a T6 injury: _____ results in paralysis below the chest

paraplegia

with a L1 injury: _____ results in paralysis below the waist

paraplegia

the top priority for a level C1-C3 spinal cord injury is _____: immediate ventilation

apnea

list some realistic functions for a patient with a level C1-C3 spinal cord injury

• ventilator

• sip-and-puff power chair

the top priorities for a level C4-C5 spinal cord injury is _____ fatigue and a weak _____

diaphragm; cough

a patient with a C5 spinal cord injury is able to _____ self with adaptive devices

feed

the top priorities for a level C6-C8 spinal cord injury is weak _____ and _____ shock

cough; neurogenic

a realistic function for a patient with a C6 spinal cord injury is a _____ _____ _____

C6 tenodesis grasp

a realistic function for a patient with a C7 spinal cord injury is _____ _____ _____

C7 independent transfers

the top priority for a level T1-T6 spinal cord injury is _____ shock now and AD later

neurogenic

list some realistic functions for a patient with a level T1-T6 spinal cord injury

• full hand use

• can operate an independent manual chair

the top priorities for a patient with a level T7-L1 spinal cord injury is _____, ileus, bladder, and skin

paraplegia

list some realistic functions for a patient with a level T7-L1 spinal cord injury

• independent

• may stand with braces

list the top priority for a patient with a level below L1 spinal cord injury: _____ bowel and bladder

flaccid

list some realistic functions for a patient with a level below L spinal cord injury

• walks with braces or crutches

The American Spinal Injury Association (ASIA) Impairment Scale determines if a spinal cord injury is complete or incomplete. The key point is any sensation or motor at ___-___ = incomplete. check voluntary _____ contraction

S4-S5; anal

neurogenic shock: protect cord perfusion - maintain a MAP ___-___ mm Hg for the first 7 days

85-90

neurogenic shock: protect cord perfusion - maintain a SBP > ___

90

neurogenic shock: protect cord perfusion - maintain a SpO2 > ___

92%

neurogenic shock: protect cord perfusion - a MAP of ___ is not enough for this cord

65

neurogenic shock: protect cord perfusion - _____ still comes first. Then rule out bleeding: no sensation means the only clue may be falling BP and rising HR

airway

neurogenic shock: protect cord perfusion - _____ without tachycardia is possible: β-blockers, older age, SCI

bleeding

neurogenic shock: protect cord perfusion - administer fluids cautiously, then _____

vasopressors

neurogenic shock: protect cord perfusion - _____ (alpha + beta) when bradycardia accompanies hypotension; phenylephrine is an option

norepinephrine

neurogenic shock: protect cord perfusion - _____ for symptomatic bradycardia; occasionally temporary pacing

atropine

neurogenic shock: protect cord perfusion - _____ triggers: suctioning, turning, hypoxia: preoxygenate

bradycardia

neurogenic shock: protect cord perfusion - _____ risks: dysrhythmias, troponin rise, acidosis

vasopressor

neurogenic shock: protect cord perfusion - _____ _____ when mobilizing: tilt slowly, abdominal binder, compression stockings

orthostatic hypotension

***for neurogenic shock, maintaining airway and breathing is priority #1

list some early warning cues (before apnea) for neurogenic shock: _____ vital capacity

falling

list some early warning cues (before apnea) for neurogenic shock: can’t count to ___ in one breath

20

list some early warning cues (before apnea) for neurogenic shock: rising PaCO2 and RR, and _____ breaths

shallow

list some early warning cues (before apnea) for neurogenic shock: paradoxical (_____) breathing

abdominal

list some early warning cues (before apnea) for neurogenic shock: ___ cough and pooled secretions

weak

list some early warning cues (before apnea) for neurogenic shock: _____ and restlessness

anxiety

list some actions for neurogenic shock: O2 to keep SpO2 > ___

92%

list some actions for neurogenic shock: _____ without neck hyperextension: jaw thrust, manual in-line stabilization

intubation

list some actions for neurogenic shock: assisted (_____) cough and suctioning

quad

list some actions for neurogenic shock: watch for bradycardia during suctioning (_____)

vagal

list some actions for neurogenic shock: _____ _____ and chest physiotherapy

incentive spirometry

list some actions for neurogenic shock: watch for pneumonia, atelectasis, and neurogenic pulmonary _____

edema

stabilization: never compromise alignment - what is it called when weights hang free; never remove. displaced? hold head neutral, call for help

skull tongs plus traction

stabilization: never compromise alignment - what is it called when there is a wrench taped to vest; pin care; never lift or turn by the ring or struts

halo vest

stabilization: never compromise alignment - what is it called when there is skin checks under pads. body jacket: vomiting and distension may be cast syndrome

braces and body jacket

stabilization: never compromise alignment - what is it called when continuous rotation for lungs and skin with unstable spine

kinetic therapy bed

how many cervical vertebrae (C…) are there

7

how many thoracic vertebrae (T…) are there

12

how many lumbar vertebrae (L…) are there

5

how many sacral vertebrae (S…) are there

5

how many coccyx vertebrae (fused together) are there

4

***for the first 72 hours, every system needs to be assessed for a patient experiencing neurogenic shock

for a patient experiencing neurogenic shock, the GI system needs to be assessed.

• ileus: administer NG tube and keep patient _____

NPO

for a patient experiencing neurogenic shock, the GI system needs to be assessed. stress ulcers peak days ___-___ so administer PPI or H2 blockers and watch Hct

6-14

for a patient experiencing neurogenic shock, the GI system needs to be assessed. feed patient within ___ hours

72

for a patient experiencing neurogenic shock, the GU system needs to be assessed. _____ on admission; later intermittent cath 4-6x/day, <400 mL. sterile in hospital, clean at home

foley

for a patient experiencing neurogenic shock, VTE needs to be assessed. SCDs now; LMWH within ___ hours unless bleeding

72

for a patient experiencing neurogenic shock, the skin system needs to be assessed. turn ___ in bed; weight shift ___ in wheelchair; never _____ red areas

q2h; q15 min; massage

for a patient experiencing neurogenic shock, the patient’s temperature needs to be assessed. _____: body takes room temperature; warm or cool the environment

poikilothermia

for a patient experiencing neurogenic shock, a hidden injury needs to be assessed. no pain below the injury: watch BP, HR, Hgb/Hct, and abdominal _____

girth