Medical-surgical Nursing Demystified

(Sean Pound) #1

(^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.



  • 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.



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