Neurological Disorders Q 148

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A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

  

     A. Bladder distension

     B. Neurological deficit

     C. Pulse ox readings

     D. The client’s feelings about the injury

    

    

Correct Answer: C. Pulse ox readings

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After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.

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Option A: Identify and monitor precipitating risk factors (bladder and bowel distension or manipulation; bladder spasms, stones, infection; skin/tissue pressure areas, prolonged sitting position; temperature extremes or drafts). Visceral distention is the most common cause of autonomic dysreflexia, which is considered an emergency. Treatment of acute episodes must be carried out immediately (removing stimulus, treating unresolved symptoms), then interventions must be geared toward prevention.

Option B: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks (“2 in above nipple line”).

Option D: Although the other options would be necessary at a later time, observation for respiratory failure is the priority. Encourage expressions of sadness, grief, guilt, and fear among the patient, SO, and friends. Knowledge that these are appropriate feelings that should be expressed may be very supportive to the patient and SO.

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