Question

Terrell Wells, a 22-year-old man who fell 50 feet from a chairlift while skiing and landed on hard-packed snow. He was found to have to have a T10-11 fracture with paraplegia. He was taken to surgery 48 hours postaccident for spinal stabilization. He spent 2 additional days in the SICU, and is being transferred to the transition unit. The following vital signs: temperature, 100°F; blood pressure, 92/68 mm Hg; heart rate, 100 bpm; respiratory rate, 20 breaths/min. (Learning Objective 1, 2,4,5)

1. What is Spinal Shock? What is the difference between spinal shock and neurogenic shock? Is your patient in Spinal Shock or neurogenic shock?(3.33 points)

2. Is this patient at risk for Autonomic dysreflexia? (why/ why not?)(3.33 points)

3. List 3 relevant nursing diagnoses for this patient and list the interventions for each.(33 points)

Answer 1

Spinal shock refers to a state which occurs after an injury or accident to the spinal cord.In this there is loss of reflex which causes loss of sensation and alteration in motor functions (paraplegia) and the patient gradually regains the lost reflexes in about days to months.If this not occur in this time frame it can be irreversible.

In neurogenic shock the patient will have have hypotension, occasional tachycardia but Bradycardia is present and thermodysregulation.It is because of autonomic nervous system impact which is due to central nervous system damage causing severe vasodilation and leads to cellular compromise. This is a fatal case needs immediate management

The patient is experiencing spinal shock

No the patient is not at risk of autonomic dysreflexia because the injury is at level T10 and T 11.Autonomic dysreflexia is common when the injury is in the T6 or above it.

●Decreased cardiac output related to alteration in heart rate as evidenced by hypotension

Goal:to normalize the blood pressure

Nursing intervention and rationale

• Monitor vital signs (gives base line information to plan for care)
• Administer IV fluid as per order (increases the blood volume and the blood pressure )
• Administer vasoconstrictor as per order to raise blood pressure
• Assess the patient for any complaints of chest pain
• Treat the underlying cause to maintain cardiac output

Evaluation

The patient will exhibit normal blood pressure

●Altered thermoregulation related to the spinal cord injury as evidenced by increased temperature

Goal:To maintain normal temperature

Nursing interventions and rationale

• Monitor vital signs (temperature )to plan for care
• Administer antipyretics as per order
• Provide tapid sponge to bring the down the temperature

Evaluation

Patient is having a normal temperature

●Risk for impaired skin integrity related to loss of reflex ,sensation as evidenced by paralysis

Goal:

To maintain good skin integrity

Nursing intervention and rationale

• Position the patient every second hourly (relieves pressure)
• Provide backcare,massage (to improve circulation )
• Provide physical therapy ,range of motion exercise (to prevent muscle rigidity)
• Remove any soiled or wet linens diapers (moisture can increase the chance of skin peeling)
• Provide care gently (aggressive care can damage the skin )