Chapter 48 Nursing Care of Patients with Central Nervous System Disorders

Answers CHAPTER 48 NURSING CARE OF PATIENTS WITH CENTRAL NERVOUS SYSTEM DISORDERS AUDIO CASE STUDY Mr. Lisle Has a Spinal Cord Injury 1. Jack likely has a cervical injury below C3. If it were C3 or above, he would not have survived. 2. Jack has very little control over his environment or care; allowing him to direct his care not only allows some autonomy and self-esteem but is also helpful to a new student! 3. Jack is at risk for skin breakdown (which he already has), infection (respiratory, urinary, wound), deep vein thrombosis (DVT), orthostatic hypotension, renal complications, depression, substance abuse, and autonomic dysreflexia. 4. Skin: turn frequently, use pressure-reduction devices in bed and wheelchair, and monitor skin condition. Infection: monitor respiratory status, urine clarity, wound drainage, temperature, and white blood cell count. DVT: monitor legs for unequal size, redness, and swelling. Renal: monitor intake and output, urine appearance, blood urea nitrogen (BUN), and creatinine. Autonomic dysreflexia: monitor vital signs and maintain patent urine flow and bowel program. VOCABULARY 1. (9) 2. (6) 3. (1) 4. (7) 5. (2) 6. (4) 7. (5) 8. (3) 9. (8) 10. (10) DRUGS USED FOR CENTRAL NERVOUS SYSTEM DISORDERS 1. (2) 2. (3) 3. (1) 4. (5) 5. (4) CENTRAL NERVOUS SYSTEM DISORDERS 1. (9) 2. (6) 3. (1) 4. (5) 5. (7) 6. (2) 7. (8) 8. (10) 9. (4) 10. (3) SPINAL DISORDERS 1. L 2. C 3. C 4. L 5. L ALZHEIMER DISEASE 1. (3) 2. (2) 3. (1) CRITICAL THINKING: SPINAL CORD INJURY 1. These are the hallmark signs of spinal cord injury or spinal shock. Loss of vasomotor control results in vasodilation. This causes hypotension. Dilated blood vessels allow more exposure of blood to the skin surface, thereby cooling the blood and causing hypothermia. Bradycardia results from disruption of the autonomic nervous system. 1 2 Chapter 48 Answers 2. Mr. Granger no longer has full use of his respiratory muscles. Therefore, he is not able to take deep breaths. 3. (a) Cervical traction will keep his cervical spine immobile and prevent further damage to the spinal cord. (b) Administration of vasopressors may be necessary to maintain blood pressure at a level that is adequate for tissue perfusion. Intravenous (IV) fluids may be inadequate to maintain blood pressure and may result in fluid overload. (c) Loss of innervation to the bladder may result in urine retention. Intermittent or indwelling catheterization is used to prevent bladder rupture or urinary reflux. 4. Edema of the spinal cord, fatigue of respiratory muscles, or both are reducing Mr. Granger’s already compromised respiratory function. As he feels shorter of breath, he becomes more anxious, fearing that his condition is worsening. Explain to him that this is a common shortterm complication of spinal cord injury. Reassure him that if mechanical ventilation is required, it will not necessarily be a permanent situation. 5. Expect that Mr. Granger will be intubated or have a tracheostomy placed to allow for mechanical ventilation. Expect the ventilation to be necessary until the spinal cord edema has subsided. 6. Ineffective Breathing Pattern: The goal is that Mr. Granger will not experience hypoxia or respiratory arrest. Monitor his pulse oximetry and respiratory pattern frequently. At the first sign of restlessness, anxiety, or shortness of breath, inform the health care provider. Impaired Physical Mobility: The goal is for all of Mr. Granger’s care needs to be met. He will be unable to care for himself independently. Protect him from skin breakdown and other hazards of immobility. Whenever possible, give Mr. Granger choices as to how and when care will be performed. Include his significant others as much as he and they wish. 7. Mr. Granger needs simple explanations of what has happened to him and what his prognosis is. He also needs to begin to learn to direct his care. This will improve his ability to function outside of the hospital. After he is stable, he will likely be transferred to a rehabilitation facility to continue to learn self-care. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. A structured environment provides a quiet setting with minimal distractions. (1, 3, 4) could all increase the patient’s agitation. 2. (1) is correct. Decreasing level of consciousness is a symptom of increasing intracranial pressure. (2, 3, 4) are incorrect. Sympathetic and parasympathetic responses and increased cerebral blood flow does not cause decreased level of consciousness. 3. (3) is correct. Widening pulse pressure warns of increasing intracranial pressure. (1, 2, 4) do not occur in increased intracranial pressure. 4. (2) is correct. Elevation of the head of the bed reduces increased intracranial pressure. (1, 3, 4) all can potentially increase increased intracranial pressure. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 5. (3) is correct. This addresses the patient’s feelings and is most likely to calm her. (1, 4) are incorrect. Trying to reason with a patient who is unable to reason may be threatening. (2) is misleading; the patient is not going to find her mother. 6. (4) is correct. Ambulation is the best evidence that the patient with lumbar disk disease is mobile. (1, 3) are good outcomes but are not related to mobility. (2) relates to cervical disease, not lumbar. 7. (3) is correct. Inability to move the affected leg would not be expected and should immediately be reported to the health care provider. (1, 4) are incorrect. Incisional pain and muscle spasm are common temporary results of microdiskectomy. (2) is incorrect. Bleeding should be monitored, but a small amount does not require immediate reporting unless it is rapidly increasing. 8. (1) is correct. The patient with a brain tumor is at risk for seizures. (2, 3) are important interventions once the patient’s safety is assured. (4) is incorrect. There is no reason to place the patient in isolation. 9. (1, 3, 4, 6) can all help avoid falls. (2) is incorrect. Restraints are not recommended and may increase agitation and risk of falls. (5) is incorrect. Assisting the patient who is at risk of falls is appropriate. Encouraging independence may be appropriate for some patients but may not be appropriate if the patient is at risk for falling. 10. (1, 4) are correct. (2) is incorrect. Oral contraceptives are contraindicated because of the increased risk for deep vein thrombosis. (3) is incorrect. A diaphragm may be too difficult for the woman to insert. (5) is incorrect. Patients may not feel an intrauterine device move out of position or be aware of signs or symptoms of uterine perforation. (6) is incorrect. Fertility is not compromised by spinal cord injury, so birth control is recommended. Chapter 48 11. Injury to the C4 or C5 vertebrae on the spinal cord is most likely causing the patient to be unable to breathe without a ventilator after a motor vehicle accident. Answers 3