A nurse is caring for a client with a complete C5 spinal cord injury who was admitted 2 hours ago following a fall. Which nursing action should be the priority?
1Assess for autonomic dysreflexia symptoms
2Monitor for signs of spinal shock
3Maintain spinal immobilization and assess respiratory status✓ 정답
4Check for sensation and movement below the injury level
해설
In acute spinal cord injury, maintaining spinal immobilization and assessing respiratory status is the priority to prevent further neurological damage and ensure adequate ventilation. Other assessments are important but secondary in the immediate phase.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention in the immediate post-injury phase of a Cervical spinal cord injury (SCI). The key is understanding the timeline and the ABCs (Airway, Breathing, Circulation) of emergency care. A C5 injury is high cervical, directly affecting the phrenic nerve (C3-C5) which controls the diaphragm. The patient is only 2 hours post-injury, placing them in the Key Point!acute, unstable phase where spinal shock and respiratory compromise are the greatest immediate threats.
Answer Rationale: The correct answer is ③ Maintain spinal immobilization and assess respiratory status. This action directly addresses the two most critical, life-threatening risks in this scenario:
1. Spinal Immobilization: Any movement could cause further, irreversible damage to the spinal cord. Maintaining alignment (e.g., with a cervical collar, backboard, log-rolling) is the foundation of acute SCI care.
2. Respiratory Assessment: A C5 injury impairs the diaphragm (phrenic nerve C3-C5). The patient is at high risk for respiratory failure due to weakened breathing muscles and potential ascending edema. Assessing respiratory status (rate, depth, effort, oxygen saturation) is paramount to ensure adequate ventilation and intervene early with oxygen or intubation if needed.
Distractor Analysis:
Watch out for confusion!① Assess for autonomic dysreflexia symptoms: Autonomic dysreflexia (AD) is a late complication that typically occurs after spinal shock has resolved, often weeks to months post-injury. It is not a concern in the first 2 hours.
Watch out for confusion!② Monitor for signs of spinal shock: While spinal shock (flaccid paralysis, loss of reflexes, hypotension, bradycardia) is indeed occurring at this stage, the priority nursing action is not just to "monitor" for it. The priority is to prevent further injury and ensure survival through immobilization and respiratory support. Monitoring for spinal shock is important but secondary to the ABCs.
Watch out for confusion!④ Check for sensation and movement below the injury level: A comprehensive neurological assessment is crucial, but in the first few hours, the primary focus is on stabilization and prevention of secondary injury. Frequent sensory/motor checks are part of ongoing monitoring but are not the immediate priority over airway/breathing and spinal stability.
Related Concepts: The nursing process dictates that the first step is always assessment tied to life-threatening conditions. For any trauma patient, the sequence is Primary Survey (ABCDE). In SCI, "C-spine immobilization" is integrated into the "A" (Airway with cervical spine protection). Neurogenic shock (a component of spinal shock) involves hypotension and bradycardia due to loss of sympathetic tone, which also requires monitoring but follows respiratory stabilization.Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the Emergency Department. A 25-year-old male is brought in via ambulance after a diving accident. He is alert but reports he cannot move his arms or legs. He is on a backboard with a rigid cervical collar in place. His respiratory rate is 22 and shallow, and he has weak cough effort.
Nursing Intervention Strategy:
Immediate Action (First 5 minutes): Confirm the cervical collar is properly fitted. Do NOT remove it. Assess airway patency while maintaining in-line stabilization. Auscultate breath sounds (listening for crackles indicating pulmonary edema or diminished sounds). Apply pulse oximetry and administer supplemental oxygen via non-rebreather mask as ordered.
Ongoing Monitoring & Care (First Hour): Continuously monitor respiratory rate, depth, oxygen saturation, and accessory muscle use. Prepare for possible intubation. Maintain strict log-rolling for any positioning. Assess for other injuries (secondary survey). Insert two large-bore IVs for fluid resuscitation, but administer fluids cautiously to avoid pulmonary edema (neurogenic shock management often uses vasopressors, not just fluids).
Comprehensive Assessment & Planning: After initial stabilization, perform a detailed neurological assessment using the ASIA Impairment Scale. Collaborate with the team for urgent MRI/CT and possible administration of high-dose steroids (if within protocol timeframe).
Patient Safety and Precautions: Never hyperextend or flex the neck. Use a lift sheet for any movement. Be vigilant for signs of deteriorating respiratory function (increased work of breathing, dropping SpO2, anxiety). Bradycardia is common; have atropine at the bedside. Avoid bladder distension (can trigger autonomic dysreflexia later and worsen hypotension now).
Nursing Procedure & Medication FlowSpinal Immobilization Procedure:
1. Manual in-line stabilization is held until the patient is fully secured to a backboard with a rigid collar.
2. Log-roll with a minimum of 4 people: one at the head maintaining alignment, one at the torso, one at the pelvis, one at the legs. The team moves the patient as a single unit.
Medication Alert: If methylprednisolone is administered per protocol for acute SCI, it is typically a high-dose IV bolus followed by a continuous infusion. Monitor closely for side effects like hyperglycemia, GI bleeding, and infection.
A Word from Your Senior Nurse
"In trauma, especially with a potential spinal injury, your hands are the first line of defense for that patient's future neurological function. That initial immobilization is non-negotiable. And remember, a patient with a neck injury can stop breathing right in front of you. Your constant respiratory assessment isn't just a task; it's a lifesaving vigil. On the NCLEX, they love to test if you know *when* to do things. Autonomic dysreflexia is critical to know, but it's not the answer in the first golden hour. Always think: 'What will kill my patient first?' That's your priority."
Spinal Shock — A temporary state of reflex depression and flaccid paralysis below the level of injury, accompanied by hypotension and bradycardia (neurogenic shock), occurring immediately after acute spinal cord injury.
Autonomic Dysreflexia — A life-threatening, uninhibited sympathetic response to a noxious stimulus below the level of injury in patients with SCI at T6 or above, characterized by severe hypertension, bradycardia, headache, and diaphoresis.
Phrenic Nerve — The nerve arising from cervical spinal nerves C3, C4, and C5 that provides motor innervation to the diaphragm. "C3, C4, C5 keeps the diaphragm alive."
Neurogenic Shock — A distributive shock caused by the loss of sympathetic tone after high spinal cord injury, leading to vasodilation, hypotension, and bradycardia (unlike hypovolemic shock which causes tachycardia).
ASIA Impairment Scale — The International Standards for Neurological Classification of Spinal Cord Injury; a standardized tool used to document motor and sensory function to determine the level and completeness of injury.