Scenario T.W. is a 22-year-old man who fell 50 feet from a chairlift while skiing and landed on hard-packed snow. He is now at the emergency department (ED) with a suspected T5-T6 fracture with paraplegia. 1. Describe a plan for implementing these physician's orders. - Implementing a plan will involve understanding what priorities need to come first for this patient. I would start by immobilizing the patient’s spine so that we are not taking any chance of further spinal damage. Then I would place them on a 4L nasal cannula. Next, I would initiate two large-bore IVs for any medications and fluid that will need to be administered quickly. I would then connect the patient to ECG monitoring. Then insert a foley catheter for any incontinence, and lastly grab a warming blanket as needed for this patient, and complete the first neurological assessment to get a baseline of where this patient is at neurologically and with what deficits. 2. What are the nursing priorities at this time? - The main priorities are to immobilize this patient’s spine to prevent any further spinal damage and to apply oxygen and make sure that this patient has a patent airway and that there is perfusion and oxygenation. Next would be IV fluids and medications and neurological assessment. 3. Which assessment would you complete first? a. Assessing ability to move the extremities b. Determining pupil response to light c. Auscultating breath sounds d. Testing the peripheral reflexes 4. What other interventions would likely be done by the ED nurse? - If there are any cuts, wounds, abrasions that happened from the fall then the ED nurse will need to do a physical assessment and provide any wound care, irrigation, and bandaging. The nurse will also need to assess the cranial nerves, motor function and mobility, and peripheral senses and all peripheral pulses as well. The nurse should also assess bowel and bladder function. 5. Awareness of the prehospital management of a spinal cord injury (SCI) is critical to T.W.'s ultimate neurologic outcome. What actions will the nurse take to ensure this goal is met? - To ensure that this goal is met the nurse will need to obtain a detailed history of the accident and what happened after the injury occurred. The nurse will gather information from the first responders on the scene and contact the family for further information. If there was anyone on the chair lift with this patient then she will need to obtain information about the fall, and what took place after the fall and how long it took for paramedics to arrive, and if this patient was moved in that timeframe. 6. The physician orders the following for T.W.: Intravenous (IV) methylprednisolone (SoluMedrol), bolus of 30mg/kg over 15 minutes, followed by a maintenance infusion of 5.4mg/kg body weight per hour. T.W. weighs 176 pounds. How many milligrams of methylprednisolone (Solu-Medrol) will T.W. receive with the bolus? - 2,400 mg with the bolus How many milligrams per hour will T.W. receive with the maintenance infusion? - 432 mg/ hr What effect will this medication have on T.W.? - Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol) is a synthetic glucocorticoid, primarily prescribed for its anti-inflammatory and immunosuppressive effects. It is either used at low doses for chronic illnesses or used concomitantly at high doses during acute flares. It will Decrease immune system response to various diseases to reduce symptoms such as swelling, pain, and allergic reaction. CASE STUDY PROGRESS Although T.W.'s injury is at a level where independent respiratory function is expected, he experiences low oxygen saturation levels and is placed on a mechanical ventilator. The physician states that this is because of spinal shock. 7. How would you explain spinal shock to T.W.'s family and why T.W. requires mechanical ventilation at this time? - Initially, in most spinal cord injuries, there is a period of flaccid paralysis with a complete loss of motor, sensory, and reflex functions below the level of injury. This period of areflexia, as spinal shock might be referred to, is temporary; it occurs shortly after the spinal cord injury, and it might last days to weeks. The loss of systemic sympathetic vasomotor tone might result in vasodilation, increased venous capacity, and hypotension. During this time, the patient might need temporary respiratory support. The return of sacral reflexes indicates resolution. 8. List three critical potential infections that T.W. will be monitored for throughout his hospitalization. - Urinary tract infection - Spinal cord injury - Foley catheter CASE STUDY PROGRESS The diagnosis of the fracture is confirmed and T.W. is transferred from the ED to the surgical intensive care unit (SICU). T.W. is taken to surgery 48 hours after the accident for spinal stabilization. He spends 2 additional days in SICU and 5 days in the neurology unit and now is in the rehabilitation unit. He continues to have paralysis of his lower extremities. Shortly after the transfer, T.W. turns on his call light and asks for medication for headache. As you walk into the room, you immediately note that T.W.'s face is flushed and he is profusely sweating. 9. What complication do you suspect T.W. is experiencing and why? - I believe he is experiencing autonomic dysreflexia because he did experience an injury at T6, he is presenting with symptoms such as facial flushing, headache, and he is diaphoretic. 10. What further assessment data do you need to collect? - Assess if he has bladder distention and when was his last bowel movement