N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide is autonomic dysreflexia, which can manifest itself at any time after the injury. It is precipitated by constipation or a full bladder and causes sympathetic reflexes, such as flushing, bradycardia, headache, and increased blood pressure. This condition can be managed by simply relieving the offending problem such as catheterization, use of laxatives, and pain control. Signs and symptoms of spinal cord injury: • Loss of feeling in limbs • Respiratory distress or failure • Paralysis of muscles below level of injury • Weakness • Absent reflexes • Incontinence of urine and feces • Loss of vasomotor responses • Loss of vibratory senses • Brown-Sequard syndrome (one-sided loss) • Decreased pain and temperature sensation Nursing assessment for spinal cord injury: • Assess location of injury and history of how injury occurred • Assess GCS, respiratory function, and efforts; breathsounds • Vital signs: temperature, pulse, respiration, and bloodpressure • Pulse oximetry • Neurological examination: pupils, sensory, verbal, and motor responses; strength of extremities • Check skin for signs of trauma and otherwounds • Review laboratory and radiology reports: o CBC: Check HCT and HGB for signs of bleeding; WBCs for signs of acute infection o ABGs: Check for signs of acute hypoxemia due to respiratory distress or failure o X-ray: Leave patient strapped to board, do not remove cervical collar o Myelogram: Dye is inserted into the subarachnoid space in the spinal column to assess for injuries, lesions, swelling, and compression o MRI/CT: Can check for soft tissue trauma, internal bleeding, organ damage, and extent of injuries Nursing diagnosis for spinal cord injury: • Impaired gas exchange related to respiratory distress and failure • Ineffective breathing pattern related to paralysis and weakness of abdominal/thoracic muscles • Risk for autonomic dysreflexia related to irritation/stimulation of sympathetic nerves • Impaired physical mobility related to paralysis/weakness ©2017 Achieve Test Prep Page 103 of 204

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