1, List the nursing assessment of acute spinal cord injury, Cervical 5 level.

Include

 Priority assessment
 Rationale for each of the above

Answer

1. Respiratory status:  if injury below C4, spinal cord edema and hemorrhage can affect
the function of the phrenic nerve and cause respiratory insufficiency.

2.Cardiac system: any cord injury above the level of T6 greatly decreases the influence of
SNS and bradycardia occurs, peripheral vasodilation occurs and cause hypotension and
decreases cardiac output.

3.Urinary retention: retention is common in acute SCI and spinal shock. 

4. GI system: primary problem is hypomotility which can lead to paralytic ileus and
gastric distention.

5. Integumentary system: due to lack of movement, skin integrity is at risk.

6.Thermoregulation:  poikilothermism occurs b/c of interruption to the SNS and prevents

temperature sensation from reaching the hypothalamus.

7.Metabolic Needs:  NG suction may lead to metabolic alkalosis, and decreased tissue
perfusion and may lead to acidosis

8. DVT: common problem during first 3 months.

2, List the nursing assessment for an acute subdural bleed. Include the following

 Prioritize
 List the short rationale for each.

Answer

A person with subdural hemorrhage may appear normal for the first 2 days, b/c
symptoms of subdural hemorrhage have a slower onset than those of epidural
hemorrhages because the lower pressure veins bleed more slowly than arteries. Thus,
signs and symptoms can be delayed as much as 2 weeks. ICP will be increased if the
bleeds are large enough, s/s of increased ICP or damage to part of the brain will be
present.

Other s/s can include the following: A hx of head injury; changed LOC; Pain; Numbness;
Irritability; Amnesia; Weakness or lethargy; Nausea or vomiting; Loss of appetite;
Personality changes; Seizures; Headache; Dizziness; Disorientation; Altered breathing
patterns; Inability to speak or slurred speech; Ataxia, or difficulty walking; Deviated
gaze, Blurred Vision; or abnormal movement of the eyes.
-Acute subdural hematoma manifests within 24-48 hours of the injury.

-decreasing LOC and headache. Pt's appearance may range from drowsy, confused to
unconscious.

(A person may appear normal for the first 2 days, but slowly become confused and then
unconscious several days later. This results from a slower rate of bleeding, causing a
slowly enlarging subdural hematoma.)

-ipsilateral pupil dilates and becomes fixed if ICP is significantly elevated.

-cerebral edema from blunt force injuries.

Model Answer

Symptoms of subdural hemorrhage have a slower onset than those of epidural

hemorrhages because the lower pressure veins bleed more slowly than arteries. Thus,
signs and symptoms may show up within 24 hours but can be delayed as much as 2
weeks.[3] If the bleeds are large enough to put pressure on the brain, signs of increased
ICP or damage to part of the brain will be present.[2]

Other signs and symptoms of subdural hematoma can include any combination of the
following:

 A history of recent head injury

 Loss of consciousness or fluctuating levels of consciousness
 Irritability
 Seizures
 Pain
 Numbness
 Headache (either constant or fluctuating)
 Dizziness
 Disorientation
 Amnesia
 Weakness or lethargy
 Nausea or vomiting
 Loss of appetite
 Personality changes
 Inability to speak or slurred speech
 Ataxia, or difficulty walking
 Altered breathing patterns
 Blurred Vision
 Deviated gaze, or abnormal movement of the eyes.[2]

3,what would be a priority nursing diagnosis for a cerebral bleed, include

Outcome, interventions and rationales: assessment, independent, dependent, colaberative.

Ineffective cerebral tissue Perfusion related to Interruption of blood flow by cerebral
hemorrhage evidenced by Altered LOC, memory loss, changes in motor or sensory responses,
restlessness, and changes in vital signs.

Outcomes: will improve LOC, cognition, motor or sensory function, demonstrate stable vital
signs and absence of signs of increased ICP by discharge.

interventions and rationales:

Assessment: Assess vital sign, air way, and assess factors related to the situation, cause for
bleeding and potential for increased ICP. Influences choice of interventions. Assess pt HX, Assess
neurological status frequently and compare with baseline: GCS during first 48 hours. Evaluate
eye opening, Assess verbal response; note whether client is alert, oriented or is confused, Assess
motor response to simple commands, noting purposeful and nonpurposeful (posturing)
movement. GCS assesses trends and potential for increased ICP and is useful in determining
location, extent, and progression or resolution of CN) damage. Monitor vital signs, BP,
respirations, and other dysrhythmias; Hypovolemia or hypotension associated with cerebral
bleeding. Evaluate pupils, noting size, shape, equality, and light reactivity. Assess position and
movement of eyes; Pupil reactions are regulated by the oculomotor (III) cranial nerve and are
useful in determining whether the brainstem is intact. Monitor and document neurological
status frequently and compare with baseline: GCS during first 48 hours. Assess GI, GU, bladder
incontinence, Note presence or absence of reflexes—blink, cough, gag, and Babinski; Altered
reflexes reflect injury at level of midbrain or brainstem and have direct implications for client
safety. Assess blood type, volume of loss for blood transfusion.

Independent:

Maintain adequate cerebral oxygenation and perfusion: ensure patent airway; Elevation of head
of bed to 30 degrees and maintain head and neck in midline or neutral position. Established IV
access to infuse blood, normal saline or lactated ringer’s solution; control external bleeding with
sterile pressure dressing. Reduces hypoxemia, which is known to increase cerebral vasodilation
and blood volume, elevating ICP.

Monitor: monitor ICP, temperature and regulate environmental temperature, as indicated.

Fever may reflect damage to hypothalamus. Monitor intake and output; Observe for seizure
activity and protect client from injury; Seizures can occur as a result of cerebral irritation,
hypoxia, or increased ICP. Monitor vital signs, LOC, HR, GCS score, Monitor ABGs or pulse
oximetry.

Call MD if pt. has a fever, dysrhythmia, decreased LOC, seizures, coma, and decreased oxygen
saturation.

Dependent: Administer supplemental oxygen via appropriate route, such as mechanical

ventilator and mask, to maintain appropriate O2 saturation, as indicated. Administer
medications, as indicated, for example: Barbiturates, such as pentobarbital, Steroids, such as
dexamethasone (Decadron) and methylprednisolone (Medrol) edema—decreasing
inflammation; Anticonvulsant, such as phenytoin (Dilantin); Chlorpromazine (Thorazine) for
treatment and prevention of seizure activity; Mild analgesics and sedatives, such as lorazepam
(Ativan) to relieve pain and agitation and their negative effects on ICP., Antipyretics, such as
acetaminophen (Tylenol) Reduces or controls fever.

Collaborative: consult nutrition therapy, respiratory therapy, prepare for surgical intervention,
such as craniotomy or insertion of ventricular drain or ICP pressure monitor, if indicated, and
transfer to higher level of care. Client may require decompressive craniotomy to remove a
section of the skull and make an incision in the dura so that the brain can expand, relieving
pressure. Craniotomy may also be performed to remove bone fragments, elevate depressed
fractures, evacuate hematoma, control hemorrhage, and debride necrotic tissue.