Case study 70 & Concept Map Spinal Cord Injury (A Graded) Latest Questions and Complete Solutions

Case study 70 & Concept Map Spinal Cord Injury (A Graded) Latest Questions and Complete Solutions Case study 70: Spinal Cord Injury T.W. is a 22-year-old man who fell 50 feet from a chairlift while skiing and land on hard-packed snow. He is now at the emergency department (ED) with suspected T5 -T6 fracture with paraplegia. Physicians orders: - Insert Foley catheter - ECG monitoring - Immobilize the cervical spine - Oxygen at 4L per nasal cannula - Initiate two large bore IV’s - Neurologic assessment every hour - Apply warming blankets as needed 1. Describe a plan for implementing these physicians’ orders. a. Before doing anything, the patient’s ABC’s should be assessed. First airway, then breathing, and then circulation. The oxygen should be given first, but the cervical spine should not be moved when putting the nasal cannula in place. Then the patient should be attached to the ECG monitor, then the 2 large bore IV’s should be initiated. Following the IV’s should be the neuro assessment, and blanket if necessary. Then las t the Foley catheter should be inserted. 2. What are the nursing priorities at this time? a. The patient’s ABC’s are priority. The airway should be open, maintaining ventilation, adequate circulation. Safety is also an issue and immobilization should be kept in order to prevent any other injuries from happening. 3. Which assessment would you complete first? a. Assessing ability to move the extremities b. Determining pupil response to light c. Auscultating breath sounds d. Testing the peripheral reflexes 4. What other interventions would likely be done by the ED nurse? a. Ensuring immobilization of cervical and thoracic spine b. Inserting NG tube c. Replacing IV fluids d. Maintaining adequate skin care e. Suction and mechanical ventilation kit available f. Assess Input and output g. Assess for bladder distention h. PROM for extremities to reduce contractures