(^248) Medical-Surgical Nursing Demystified
- prednisone
- dexamethasone
- Administer dextran, a plasma expander, which increases blood flow in the
spinal cord, increasing oxygenation to the tissue. - Assist respirations if indicated.
- Administer H2 receptor antagonists to protect stomach from stress ulcer formation:
- cimetidine, ranitidine, famotidine, nizatidine
- Administer gastric mucosal protective agent to coat stomach lining:
- sucralfate
- Place patient in a rotation bed for repositioning to prevent pressure on skin.
- Surgical repair of vertebral fracture or decompression may be necessary.
NURSING DIAGNOSES
- Impaired physical mobility
- Powerlessness
NURSING INTERVENTION
- Monitor respiratory status—assess for changes in rate, effort, use of acces-
sory muscles, cyanosis, altered mental status, and pulse oximetry reading. - Monitor neurologic status for changes—assess sensation, temperature, touch,
position sense, comparing right to left. - Monitor for spinal shock:
- Flaccid paralysis, loss of reflexes below the level of injury, hypotension,
bradycardia, possible paralytic ileus.
- Flaccid paralysis, loss of reflexes below the level of injury, hypotension,
- Monitor pulse and blood pressure for changes—change in heart rate, hypo-
tension, or hypertension. - Assess skin for signs of pressure (redness) or breakdown.
- Assess abdomen and listen for bowel sounds.
- Explain to the patient:
- Importance of regular bowel and bladder function to avoid autonomic
dysreflexia due to distension: severe headache, hypertension, bradycardia,
flushing, nasal congestion, sweating, nausea. - Use of incentive spirometer.
- Importance of regular bowel and bladder function to avoid autonomic