SCI 3

Nursing Interventions for T4 Spinal Cord Injury

• Prioritize monitoring for autonomic dysreflexia with a T4 spinal cord injury because it's a life-threatening emergency needing immediate intervention
• Autonomic dysreflexia is a risk for patients with injuries at T6 or above

Nursing Education for C6 Spinal Cord Injury

• Further teaching is needed if a patient with a C6 spinal cord injury states that they don't need to worry about pressure ulcers since they can feel their skin
• Patients with spinal cord injuries have sensory deficits and are at high risk of pressure ulcers requiring frequent skin assessments

Nursing Actions for T6 Spinal Cord Injury

• Check the bladder for distension first if a patient with a T6 spinal cord injury has a pounding headache, flushed skin, and high blood pressure
• A distended bladder is the most common cause of autonomic dysreflexia

Assessment Findings Needing Immediate Intervention for C3 Spinal Cord Injury

• Respiratory distress requires immediate intervention for a C3 spinal cord injury
• C3 injuries affect the diaphragm, leading to respiratory compromise

Best Nursing Intervention for T12 Spinal Cord Injury

• Orthostatic hypotension is common in spinal cord injury patients due to loss of vasoconstriction
• Gradual position changes reduce sudden drops in blood pressure

Appropriate Nursing Action for patient with paraplegia

• Assess for bowel sounds and monitor for ileus when a patient with paraplegia complains of persistent nausea and bloating
• Spinal cord injury patients are prone to paralytic ileus due to decreased bowel motility

Nursing Interventions for Neurogenic Shock

• Appropriate interventions for neurogenic shock include administering IV fluids, monitoring for bradycardia, and applying sequential compression devices
• Neurogenic shock leads to hypotension and bradycardia due to loss of sympathetic tone
• Fluid resuscitation, compression devices, and close monitoring are needed for neurogenic shock

Nursing Care for Severe Headache in Paraplegia

• Assess blood pressure immediately for a patient with paraplegia reporting a new onset of severe, throbbing headache
• Severe headaches can be a sign of autonomic dysreflexia

Preventive Measures for DVT in Spinal Cord Injury

• Implement range-of-motion exercises, apply compression stockings, and administer prophylactic anticoagulants for a patient with a spinal cord injury at risk for DVT
• Immobility increases DVT risk, and preventative measures include movement, compression therapy, and anticoagulants

Assistive Devices for C7 Spinal Cord Injury

• A manual wheelchair is the most appropriate assistive device for independent mobility for a patient with a C7 spinal cord injury
• A C7 injury allows for limited upper limb function, making a manual wheelchair the best choice for independent mobility

Nursing Response for T1 Spinal Cord Injury

• An appropriate response to a patient with a T1 injury reporting difficulty maintaining an erection is to say there are medications and devices that may help
• Spinal cord injuries can affect sexual function, but treatments like PDE-5 inhibitors and assistive devices are available

Self-Care Education for Spinal Cord Injury

• Indicate understanding by stating that they should shift their weight every 30 minutes to prevent pressure ulcers
• Frequent weight shifts help prevent pressure ulcers

Priority Nursing Action for T8 Spinal Cord Injury

• Obtain a urine sample for culture when a patient with a T8 injury has a low-grade fever, cloudy urine, and foul-smelling urine because this indicates a UTI
• Fever and foul-smelling urine suggest a UTI, a common complication

Nurse's First Action for T6 Spinal Cord Injury Patient

• Check for bladder distension as the initial action for a patient with a T6 injury experiencing excessive sweating above the injury site
• Excessive sweating can be a symptom of autonomic dysreflexia, often caused by bladder distension

Nursing Priority Action for Spinal Cord Injury at T4

• Signs of autonomic dysreflexia include severe nasal congestion and blurry vision
• Raise the head of the bed to decrease blood pressure

Key Focus of Care

• Bowel and bladder management should be a key focus of care in a care plan for a patient with a spinal cord injury at L1 because lumbar injuries impact lower body function
• Lumbar injuries impact lower body function requiring bowel and bladder training but do not affect respiration

Understanding DVT Prevention

• Patients should move their legs frequently to prevent DVT
• Movement, even passive range-of-motion exercises, reduces DVT risk in immobile patients

Intervention for C5 Spinal Cord Injury

• Administer atropine as prescribed because neurogenic shock causes bradycardia and hypotension, and atropine increases heart rate

Priority Assessment

• Assess for signs of bleeding because Heparin increases bleeding risk

Spinal Cord Injury Management

• Assess the bladder for distension

First Action Reddened Sacrum

• The first action is to reposition the patient

Autonomic Dysreflexia Assessment Findings

• It leads to severe hypertension, bradycardia, sweating, and flushing above the injury level due to overactive sympathetic responses

Prevention of Contractures

• Passive range-of-motion exercises best prevents contractures

Self-Catheterization Understanding for C7 Spinal Cord Injury

• Scheduled catheterization every 4-6 hours prevents urinary retention and autonomic dysreflexia

C4 Injuries

• Impairs coughing ability, requiring suctioning and postural drainage for secretion clearance

Developing a Care Plan T1 Spinal Cord Injury

• Maintain Skin Integrity because of immobility and pressure ulcer risk

Patient Expressing Frustration Care

• Provide information on available support groups so patients can adjust to new challenges

Walking after L5 injury

• Patient may be able to walk using braces and assistive devices but functional recovery varies

Assessment Findings for T12

• Requires immediate intervention for severe hypotension suggests neurogenic shock

Teaching Intervention

• "I will shift my weight every 15 minutes because frequent weight shifts prevent pressure ulcers in immobile patients