RATIONALE: The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to
intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function.
CLIENT NEED: Management of care;
COGNITIVE LEVEL: Analyze
CORRECT ANSWER:
C,D,E
Sets found in the same folder
What are nursing interventions for increased ICP?
Nursing Interventions
Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload. The patient must be stabilized before transport to radiology for brain imaging.
What is the treatment for increased ICP?
Treatment might include: Taking medicine to reduce swelling. Draining extra cerebrospinal fluid or blood around the brain. Removing part of the skull (craniotomy) to ease swelling (though this is rare)
Which intervention would be contraindicated for a client being treated for increased intracranial pressure ICP )?
Which of the following is contraindicated in a patient with increased ICP? The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation.
What are the measures used to decrease ICP?
Hyperventilation reduces ICP by lowering PaCO2 , which causes vasoconstriction. The respiratory therapist induces hyperventilation by adjusting ventilator settings as ordered and monitoring arterial blood gases (ABGs). Usually, PaCO2 should be decreased no lower than 30 mm Hg.