N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide • Risk for skin breakdown related to immobility and sensory dysfunction • Risk for injury related to decreased sensory and motor responses Nursing interventions for spinal cord injury: • Closely monitor respiratory functions; support a patent airway • Be prepared for intubation; never hyperextend neck and shoulders • Perform CPR with oxygen bagging if needed • Take vital signs often • Give supplemental oxygen if needed • Re-assess neurological status and GCS: assess for headache, vision issues, sweating, and flushing (autonomic dysreflexia) • Take care when working with patients in the field; allow EMS personnel to handle patient, stand back and follow their instructions; even in the ER, do not move the patient unless told to do so; do not remove board or cervical collar • Assist with immobilization efforts: o Halo vest: Immobilizes upper body while allowing for movement of extremities; for use only when patient is stable o Vinke or crutchfield tongs: Traction for neck injuries by weights and pulleys; adverse effects include infections or movement of tongs; monitor closely o Stryker frame or rotorest beds: Helps to turn patient and prevents skin breakdown, pneumonia, or autonomic complications • Give medications per MD orders: o Anti-inflammatories: Steroids can prevent edema from trauma and further compression of the spinal cord o Blocking agents: Hydralazine can reduce autonomic dysreflexia symptoms o Pain medications: Even with paralysis, most patients still perceive pain • Preparation for surgery if needed: laminectomy or spinal decompression • Insert foley catheter if necessary and monitor bowel function; treat distention promptly to prevent autonomic complications • Per MD and physical therapy orders: place patient in compression stockings or place patient in Trendelenberg position to prevent hypotension (lower head/elevate feet) • After patient is stable and removed from board, carefully turn every twohours • Provide adequate skin care to prevent breakdown; smoothsheets • Promote drainage of secretions; suction carefully; use deep breathing; caution with coughing • Keep room dark and quiet; limit visitors if patient exhibit signs of autonomic sensitivity • Maintain patient safety: call light close, bed rails up, and bed in low position • Provide appropriate nutrition and fluids; monitor gag reflex to preventaspiration ©2017 Achieve Test Prep Page 104 of 204