Problem
It is the start of your 12-hour shift. You are assigned to Daniel R., a 25-year-old injured in a diving accident 3 days ago. He dove into a sandbar at a remote river; alcohol was positive in the trauma toxicology screen, negative for other substances. He was diagnosed with a C4 burst fracture and a C4 ASIA A injury. The initial CT of his head was negative for any bleed. He had a posterior spinal fusion from C3 to C5 on the day of injury and is immobilized in a cervical collar. He has remained in sinus rhythm. Over the last 24 hours his forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) have been steadily decreasing. Last night his SpO2 dropped to 82% and would only maintain at 90% with high concentrations of oxygen via a reservoir nasal cannula. Trauma anesthesia was called, and Daniel was endotracheally intubated with a fiberoptic scope. He has remained in normal sinus rhythm overnight with pulse oximetry remaining at or above 98%. You are completing your assessments, as follows:
• Vital signs: temp 99.8°F, HR 6/min, BP 100/72, with SpO2 of 98%
• Pulmonary assessment: Breath sounds are diminished in the bases (right worse than left) with coarse rhonchi.
• Abdominal assessment: Bowel sounds are diminished, and abdomen is palpable but slightly distended.
• Peripheral perfusion assessment: Lower leg pulses are strong bilaterally; no redness, warmth, or swelling noted. No compression devices are present.
• Skin assessment: A purple discolored area is noted on the coccyx.
• Examine Daniel's peripheral perfusion and skin assessments. What orders (medical and nursing) should be considered based on these findings?
• Based on Daniel's presentation, what mechanism of injury is likely to be associated with his SCI, and what other associated injuries are likely to be present?
• It has now been 48 hours since the injury. What are the priorities of caring for him now?
• Describe interventions that Daniel will likely require to minimize complications of prolonged immobilization.
Clinical Update: It is now 1 month post-SCI, and Daniel exhibits reflex activity. He calls you to his room and complains of a severe headache. You note flushing and decide to take his BP. It is 180/95. Normally his BP is around 112/68. His pulse is 60. You remember that since yesterday he no longer has an indwelling urinary catheter for bladder training.
• What is occurring, and what need to be done about it?
He was diagnosed with a C4 burst fracture and a C4 ASIA A injury. The initial CT of his head was negative for any bleed. He had a posterior spinal fusion from C3 to C5 on the day of injury and is immobilized in a cervical collar. He has remained in sinus rhythm. Over the last 24 hours his forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) have been steadily decreasing. Last night his SpO2 dropped to 82% and would only maintain at 90% with high concentrations of oxygen via a reservoir nasal cannula. Trauma anesthesia was called, and Daniel was endotracheally intubated with a fiberoptic scope. He has remained in normal sinus rhythm overnight with pulse oximetry remaining at or above 98%. You are completing your assessments, as follows:
1. Vital signs: temp 99.8°F, HR 6/min, BP 100/72, with SpO2 of 98%
2. Pulmonary assessment: Breath sounds are diminished in the bases (right worse than left) with coarse rhonchi.
3. Abdominal assessment: Bowel sounds are diminished, and abdomen is palpable but slightly distended.
4. Peripheral perfusion assessment: Lower leg pulses are strong bilaterally; no redness, warmth, or swelling noted. No compression devices are present.
5. Skin assessment: A purple discolored area is noted on the coccyx.
• Examine Daniel's peripheral perfusion and skin assessments. What orders (medical and nursing) should be considered based on these
findings?
• Based on Daniel's presentation, what mechanism of injury is likely to be associated with his SCI, and what other associated injuries are likely to be present?
• It has now been 48 hours since the injury. What are the priorities of caring for him now?
• Describe interventions that Daniel will likely require to minimize complications of prolonged immobilization.
Clinical Update: It is now 1 month post-SCI, and Daniel exhibits reflex activity. He calls you to his room and complains of a severe headache. You note flushing and decide to take his BP. It is 180/95. Normally his BP is around 112/68. His pulse is 60. You remember that since yesterday he no longer has an indwelling urinary catheter for bladder training.
• What is occurring, and what should you do about it?