Medical-surgical Nursing Demystified

(^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.