which finding in a patient with a spinal cord tumor is most important for the nurse to report

Nursing Diagnosis: Acute Pain related to physical trauma or injury, secondary to spinal cord injury, as evidenced by onset of hyperesthesia directly above the point of injury, paraplegia, burning sensation beneath the site of the injury, phantom pain, spasticity of the muscles, and headaches.

Full Answer

How is a spinal cord tumor diagnosed?

MRI scan of spinal cord tumor. If your doctor suspects a spinal tumor, these tests can help confirm the diagnosis and pinpoint the tumor's location: Spinal magnetic resonance imaging (MRI). MRI uses a powerful magnetic field and radio waves to produce accurate images of your spine, spinal cord and nerves.

Which assessment is appropriate for a patient with a C5 spinal cord injury?

Assessment of neurologic and respiratory status is appropriate. Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia

What is a spinal cord injury Quizlet?

Join NURSING.com to watch the full lesson now. The spinal cord is the bundle of nerves that comes off of the brain stem, runs down through the vertebral column, and branches out to innervate the entire body. A spinal cord injury means that nerve impulses below that point will no longer be sent.

How do doctors treat spinal tumors?

Doctors also can monitor the function of the spinal cord and other important nerves during surgery, thus minimizing the chance of injuring them. In some instances, very high-frequency sound waves might be used during surgery to break up tumors and remove the fragments.

What is the most common presenting symptom of spinal tumor?

Back pain is a common early symptom of spinal tumors. Pain may also spread beyond your back to your hips, legs, feet or arms and may worsen over time — even with treatment. Spinal tumors progress at different rates depending on the type of tumor.

What are some assessment findings with a patient with a spinal cord injury?

Signs & symptoms of acute SCIFlaccid paralysis below level of injury.Loss of spinal reflexes below level of injury.Loss of sensation (pain, touch, proprioception, temperature) below level of injury.Loss of sweating below level of injury.Loss of sphincter tone and bowel & bladder dysfunction.

What are symptoms of a spinal tumor?

Vertebral tumor signs and symptoms may include:Pain at the site of the tumor due to tumor growth.Back pain, often radiating to other parts of your body.Back pain that's worse at night.Loss of sensation or muscle weakness, especially in your arms or legs.Difficulty walking, sometimes leading to falls.More items...•

What are two critical findings in a patient who has a spinal cord injury in the cervical region of the spinal cord?

Extreme back pain or pressure in your neck, head or back. Weakness, incoordination or paralysis in any part of your body. Numbness, tingling or loss of sensation in your hands, fingers, feet or toes. Loss of bladder or bowel control.

What is the most critical assessment with a spinal cord injury?

Diagnostic Assessments CT is the modality of choice in the initial work up of acute SCI.

Which of the tests results indicated a spinal cord injury and why?

Diagnostic tests for spinal cord injuries may include a CT scan, MRI or X-ray These tests will help the doctors get a better look at abnormalities within the spinal cord. Your doctor will be able to see exactly where the spinal cord injury has occurred.

How are spinal tumors detected?

Spinal magnetic resonance imaging (MRI). MRI is usually the preferred test to diagnose tumors of the spinal cord and surrounding tissues. A contrast agent that helps highlight certain tissues and structures may be injected into a vein in your hand or forearm during the test.

What is a spinal tumor?

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant (cancerous).

Where are spinal tumors usually located?

Spinal tumors can be located: Inside of your spinal cord (intramedullary). In the tissues (meninges) covering your spinal cord (intradural-extramedullary). Between the meninges and bones of your spine (extradural).

What does C3 and C4 affect?

The C3 myotome commonly includes certain neck muscles that help bend the neck forward. The C4 spinal nerve dermatome usually includes parts of skin over the shoulder. The C4 myotome includes certain muscles that help in shoulder movements.

Which represents the most common sites for spinal cord injuries?

SCI typically affects the cervical level of the spinal cord (50%) with the single most common level affected being C5 (1). Other injuries include the thoracic level (35%) and lumbar region (11%).

What assessment findings are associated with injuries of the spinal cord at the thoracic level?

The following may be associated with thoracic spine nerve damage:Significant leg weakness or loss of sensation.Loss of feeling in genitals or rectal region.No control of urine or stool.Fever and lower back pain.A fall or injury that caused the pain.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? Support selection of a high-protein diet. Discuss options for sexuality and fertility. Assist in planning a prescribed bowel program. Use quad coughing to strengthen cough efforts.

ANS: C Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be incl...

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? Hyperactive reflex activity below the level of injury Involuntary, spastic movements of the arms and legs Hypotension, bradycardia, and warm, pink extremities Lack of sensation or movement below the level of injury

ANS: C Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive...

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? Assessment of the patient for right arm weakness Assessment of the patient for increased right leg pain Positioning the patient’s left leg when turning the patient Teaching the patient to look at the right leg to verify its position

ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg....

The nurse will explain to the patient who has a T2 spinal cord transection injury that use of the shoulders will be limited. function of both arms should be retained. total loss of respiratory function may occur. tachycardia is common with this type of injury.

ANS: B The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with...

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? Teach the patient the Credé method. Instruct the patient how to self-catheterize. Catheterize for residual urine after voiding. Assist the patient to the toilet every 2 hours.

ANS: B Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to...

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to drive a car with powered hand controls. push a manual wheelchair on a flat surface. turn and reposition independently when in bed. transfer independently to and from a wheelchair.

ANS: B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and f...

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse “I want to be transferred to a hospital where the nurses know what they are doing!” Which action by the nurse is best? Clarify that abusive language will not be tolerated. Request that the patient provide input for the plan of care. Perform care without responding to the patient’s comments. Reassure the patient about the competence of the nursing staff.

ANS: B The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger...

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patient’s independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient’s care and encourage that participation.

ANS: C The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be as...

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? Cardiac monitoring for bradycardia Assessment of respiratory rate and effort Application of pneumatic compression devices to legs Administration of methylprednisolone (Solu-Medrol) infusion

ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory fu...

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardi...

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury

Correct Answer(s): D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are...

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respir...

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position

Correct Answer(s): A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder dis...

Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury? select all that apply. a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma

Correct Answer (s): a, c, d, e the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bi...

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a.Assist with selection of a high protein diet. b.Use quad coughing to assist cough effort. c.Discuss options for sexuality and fertility. d.Teach the purpose of a prescribed bowel program.

ANS: D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce th...

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a.hypotension, bradycardia, and warm extremities. b.involuntary, spastic movements of the arms and legs. c.hyperactive reflex activity below the level of the injury. d.lack of movement or sensation below the level of the injury.

ANS: A Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive...

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Squard syndrome. Which nursing action should be included in the plan of care? a.Assessment of the patient for left leg pain b.Assessment of the patient for left arm weakness c.Positioning the patients right leg when turning the patient d.Teaching the patient to look at the left leg to verify its position

ANS: C The patient with Brown-Squard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg....

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a.use of the shoulders will be preserved. b.full function of the patients arms will be retained. c.total loss of respiratory function may occur temporarily. d.elevations in heart rate are common with this type of injury.

ANS: B The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with...

What is the best test for spinal cord tumors?

MRI is usually the preferred test to diagnose tumors of the spinal cord and surrounding tissues. A contrast agent that helps highlight certain tissues and structures may be injected into a vein in your hand or forearm during the test.

How to determine if a spinal tumor is a tumor?

Biopsy. The only way to determine the exact type of a spinal tumor is to examine a small tissue sample (biopsy) under a microscope. The biopsy results will help determine treatment options.

What is the goal of spinal tumor treatment?

Treatment. Ideally, the goal of spinal tumor treatment is to eliminate the tumor completely , but this goal may be complicated by the risk of permanent damage to the spinal cord and surrounding nerves. Doctors also must take into account your age and overall health.

What is the best test to diagnose a spinal tumor?

If your doctor suspects a spinal tumor, these tests can help confirm the diagnosis and pinpoint the tumor's location: Spinal magnetic resonance imaging (MRI). MRI uses a powerful magnetic field and radio waves to produce accurate images of your spine, spinal cord and nerves. MRI is usually the preferred test to diagnose tumors ...

Why is spinal tumor overlooked?

Spinal tumors sometimes might be overlooked because they're not common and their symptoms resemble those of more common conditions. For that reason, it's especially important that your doctor know your complete medical history and perform both general physical and neurological exams. If your doctor suspects a spinal tumor, ...

Why do doctors use microscopes in microsurgery?

The high-powered microscopes used in microsurgery make it easier to distinguish tumor from healthy tissue. Doctors also can monitor the function of the spinal cord and other important nerves during surgery, thus minimizing the chance of injuring them.

What are the symptoms of spinal tumors?

If you have signs and symptoms that are common to spinal tumors — such as persistent, unexplained back pain, weakness or numbness in your legs, or changes in your bowel or bladder function , call your doctor promptly.

What is the best action by a nurse?

The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient’s ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

Can a C6 patient push a wheelchair?

The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

Is methylprednisolone safe for spinal cord injury?

Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory function. Methylpred nisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

What side of the patient with Brown-Squard syndrome will the nurse move?

The patient with Brown-Squard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patients left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.

What chapter is the SCI and Neurogenic shockdeck?

Flashcards in CHAPTER 61: SCI and Neurogenic ShockDeck (64)

Can you perform a Romberg test while standing?

Romberg test must be performed while standing therefore not suitable for unstable patient

Can a T1 injury affect the arms?

The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

Why should the patient's desire for privacy be respected?

The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

Is methylprednisolone safe for spinal cord injury?

Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone ( Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries.

Can Cauda Equina syndrome be used for bladder emptying?

ANS: A. Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate.

How to diagnose a spine tumor?

Diagnosing a spine tumor usually starts with a comprehensive medical examination to assess your symptoms. Once your treatment team has a complete diagnostic profile, they’ll customize a plan of care that fits your unique situation.

What is the best way to diagnose a spine tumor?

Because MRI is more effective for diagnosing spine tumors, myelography is mostly used to plan your treatment before using a high-dose, high-precision radiation therapy called stereotactic radiosurgery .

What is the pathologist's job to determine if a tumor is malignant or benign?

If the tumor is primary, the biopsy can determine whether it’s malignant (cancerous) or benign (noncancerous).

What is the best way to diagnose spinal cord compression?

Magnetic resonance imaging (MRI) This is the most reliable method for diagnosing spine tumors. MRI can identify spinal cord compression, even if you don’t have pain or other neurologic symptoms, and can often distinguish between malignant and benign lesions.

What is an X-ray for spinal cord?

An X-ray can identify the specific vertebra compressing your spinal cord and evaluate spine alignment. During treatment, X-rays can also help your doctor assess the placement of rods and pedicle screws used to stabilize your spine.

Why do we need imaging for spine?

Imaging is also used to see the impact of the tumor on your spine, as well as the health and stability of your vertebrae. Information from imaging tests can help determine the most effective treatment and reduce the risk of complications from surgery or radiation therapy.

What is CT scan for spine?

Computed tomography (CT) These scans use multiple X-rays to determine your tumor’s size and location and assess the quality of the bones in your spine. This helps determine the tumor’s stage (seriousness) and whether it’s metastasized (spread).

What are the symptoms of spinal cord injury?

Also, autonomic dysreflexia symptoms, which are common with spinal cord injuries include blurry vision, feeling hot, or being restless or anxious.

What is the spinal cord?

The spinal cord contains a bundle of nerves, which come off of the brainstem and innervate the body. When an injury occurs to the spinal cord, impulses will not be sent below the level of injury, including sensory and motor impulses.

What is the best way to care for a spinal cord injury?

Let’s take a look at some of the nursing interventions necessary when caring for a patient with a spinal cord injury. Immobilizing the patient and maintaining full spinal precautions until the patient is cleared by a neurosurgeon is critical. This includes placing a C-collar to immobilize the neck, keeping the head of the bed flat and using a strict log roll technique for any turning, because any twist or bend of the spine could create further damage. A halo brace is used to immobilize the cervical spine with unstable or tibial fractures. With this, four pins are inserted into the skull and Pin care must be completed twice daily to prevent or protect from infections at the pin site. Also guys, a wrench should be kept at the bedside in case the halo vest needs to be removed for chest compressions.

What do social workers do for spinal cord injury patients?

The social worker can help to set these things up for the patient.

What causes spinal cord injuries?

Spinal cord injuries are most commonly caused by trauma like a motor vehicle collision or fall , but can also be caused by penetrating trauma like stabbings or gunshot wounds that penetrate the spinal column.

What does spinal cord injury mean?

A spinal cord injury means that nerve impulses below that point will no longer be sent. This includes motor and sensory impulses. Injuries to the spinal cord could be complete, in which the spinal cord is completely severed or damaged all the way through the cord.

What is a C-collar in nursing?

This involves a c-collar to immobilize the neck, keeping the HOB flat, and using a strict log-roll technique for turning. Any twist or bend of the spine could cause further damage to the spinal cord.

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• If you have signs and symptoms that are common to spinal tumors — such as persistent, unexplained back pain, weakness or numbness in your legs, or changes in your bowel or bladder function, call your doctor promptly. After your doctor examines you, you may be referred to a doctor who is trained to diagnose and treat cancer (oncologist), brain and s...

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