NR_341 SPINAL CORD INJURY STUDY GUIDE 2022.

1. Describe a plan for implementing these physician's orders. • To implement this order I would first start by first immobilizing the cervical spine. This is considered an emergency and is critical because improper movement can cause further damage and loss of the neurological function. Next I would make sure the patient has his O2 to help facilitate his breathing, I would make sure the patient is connected to the ECG monitor next I would start the IV to have access to administer medications easily being that the patient it immobilized. After that I would complete my neurological assessment by assessing the patients motor and sensory function, testing the patient ability to squeeze my hands, move fingers and toes and monitor for signs of autonomic dysreflexia. Next I would insert foley catheter, bladder is atonic and can become over distended in spinal shock. The bladder may become hyperirritable with reflex emptying after spinal shock subsides, so this may require indwelling catheter. Lastly, I would apply the warming blanket as needed to promote thermoregulation which can be impaired by the spinal injury. 2. What other interventions might be done by the ED nurse? • The ED nurse should continuously monitor the patients respiratory status which is the first priority. Involuntary respirations can be affected due to a lesion. The nurse should provide oxygen and suction as needed, and assist with coughing by applying abdominal pressure when he patient is attempting to cough