Download Powerpoint Spinal Cord Injury and HNP (Mod 7 & 8)

Spinal Cord Injury,
Herniated Disc &
Spinal Cord Tumors
Chris Puglia, MSN, RN, CEN
Based on the Lecture by Lisa
Randall, RN, MSN, ACNS-BC
Objectives
• Consider the risk factors, signs & symptoms,
diagnostic tests, complications, and
treatments of:
– Spinal cord injury
– Herniated disc
– Spinal cord tumors
• Prioritize nursing diagnoses
• Discuss legal and ethical issues
• Case study/questions
Spinal Cord
Protection
Bonesvertebral column
7 Cervical
12 Thoracic
5 Lumbar
5 Sacral
Discsbetween
vertebra
Nervous System and the Spinal Cord
• ANS can be affected by
Spinal Cord Injury (SCI)
• Sympathetic chains on
both sides of the spinal
column (T1-L2)
• Parasympathetic
nervous system is the
cranial-sacral branch
(brainstem, S2-4)
• Reflex Arc
Etiology of Traumatic SCI
• MVC: most common cause
• Other: falls, violence, sport injuries
• SCI typically occurs from indirect injury from
vertebral bones compressing cord
• SCI frequently occur with head injuries
• Cord injury may be caused by direct trauma
from knives, bullets, etc
Spinal Cord Injury- SCI
•
•
•
•
Compression
Interruption of blood supply
Traction
Penetrating Trauma
Spinal Cord Injury
• Primary
– Initial mechanism of injury
• Secondary
– Ongoing progressive damage
• Ischemia
• Hypoxia
• Microhemorrhage
• Edema
• Hemorrhage and edema occur in the cord post injury,
causing more damage to cord
• Extension of the cord injury from cord edema can occur
over the first few days
– watch the phrenic nerve
Spinal Shock
– Decreased reflexes and loss of sensation below
the level of injury
– Motor loss: flaccid paralysis below level injury
– Sensory loss: loss touch, pressure, temperature
pain and proprioception perception below injury
– Lasts days to months
Neurogenic Shock
 Due to loss of vasomotor tone
 SNS loss results in parasympathetic dominance with
vasomotor failure
 Loss of SNS innervation causes peripheral pooling
and decreased cardiac output
 Hypotension and Bradycardia
 Orthostatic hypotension and poor temperature
control (poikilothermic)
Classifications of SCI
• Mechanism of Injury (MOI)
• Skeletal and Neurologic Level
• Completeness (degree) of Injury
Mechanism of Injury
1. Flexion
2. Hyperextension
3. Compression
4. Flexion /Rotation
Classifications of SCI
Mechanism of Injury
Flexion (hyperflexion)
• Most common because of
natural protection position.
• Generally cause neck to be
unstable because stretching
of ligaments
Classifications of SCI
Mechanism of Injury
Hyperextention
• Caused by chin hitting a
surface area, such as
dashboard or bathtub
• Usually causes central cord
syndrome symptoms
Classifications of SCI
Mechanism of Injury
Compression
• Caused by force from above
– Such as hit on head
– Or from below as landing on
butt
• Usually affects the lumbar
region
Classification of SCI
Level of Injury
Spinal cord level
 When referring to spinal
cord injury, it is the reflex arc
level (neurologic)not the
vertebral or bone level
 The thoracic, lumbar &
sacral reflex arcs are higher
than where the spinal
nerves actually leave
through the opening of
vertebral bone
Classifications of SCI
Completeness (Degree) of Injury
• Complete
• Incomplete
– Central cord syndrome
– Anterior cord syndrome
– Brown-Sequard syndrome
– Posterior cord syndrome
– Cauda Equina and Conus Medullaris
Classification of SCI
Completeness (degree) of Injury
Complete (transection)
• After spinal shock:
• Motor deficits
– Spastic paralysis below
level of injury
• Sensory
– Loss of all sensation
perception
• Autonomic deficits
– Vasomotor failure and
spastic bladder
Classification of SCI
Completeness (degree) of Injury
Incomplete
Central Cord Syndrome
• Injury to the center of the
cord by edema and
hemorrhage
• Motor weakness and
sensory loss in all
extremities
• Upper extremities affected
more
Classification of SCI
Completeness (degree) of Injury
Incomplete
Brown-Séquard Syndrome
• Hemisection of cord
• Ipsilateral paralysis
• Ipsilateral superficial
sensation, vibration and
proprioception loss
• Contralateral loss of pain
and temperature
perception
Classification of SCI
Completeness (degree) of Injury
Incomplete
Anterior Cord Syndrome
• Injury to anterior cord
• Loss of voluntary motor,
pain and temperature
perception below injury
• Retains posterior column
function (sensations of
touch, position, vibration,
motion)
Classification of SCI
Completeness (degree) of Injury
Incomplete
Posterior Cord Syndrome
• Least frequent syndrome
• Injury to the posterior
(dorsal) columns
• Loss of proprioception
• Pain, temperature,
sensation and motor
function below the level of
the lesion remain intact
Classification of SCI
Completeness (degree) of Injury
Incomplete
Conus Medullaris
 Injury to the sacral cord
(conus) and lumbar nerve
roots
Cauda Equina
 Injury to the lumbosacral
nerve roots
 Result = areflexic (flaccid)
bladder and bowel, flaccid
lower limbs
Clinical Manifestations of SCI
• Skin:
- pressure ulcers
• Neuro:
- pain
- sensory loss
- upper/lower motor
deficits
- autonomic dysreflexia
• Cardio:
- dysrhythmias
- spinal shock
- loss of SNS control over
blood vessels
- orthostatic hypotension,
- poikilothermic
Clinical Manifestations of SCI
• Respiratory:
– decrease chest
expansion, cough
reflex & vital capacity
– diaphragm functionphrenic nerve
• GI:
– stress ulcers
– paralytic ileus
– bowel- impaction &
incontinence
• GU:
– upper/lower motor
bladder
– impotence
– sexual dysfunction
• Musculoskeletal:
–
–
–
–
–
–
–
joint contractures
bone demineralization
osteoporosis
muscle spasms
muscle atrophy
pathologic fractures
para/tetraplegia
Common Manifestation/Complications
Upper and Lower Motor Deficits
• Upper motor deficits result
in spastic paralysis
• Lower motor deficits result
in flaccid paralysis and
muscle atrophy
Common Manifestations/Complications
• Spinal cord injuries are described by the level of the injury
– the cord segment or dermatome level
– such as C6; L4 spinal cord injury
• Terms used to describe motor deficits
– Prefix:
• para- meaning two extremities
• tetra- or quadra- all four extremities
– Suffix:
• -paresis meaning weakness
• -plegia meaning paralysis
Quadraparesis means what?
Common Manifestations/Complications
• C1-3 = usually fatal
• Loss of phrenic innervation
= ventilator dependent
• No B/B control
• Spastic paralysis
• Electric w/c with
chin/mouth control
Common Manifestations/Complications
• C6 = weak grasp
• Has shoulder/biceps to
transfer & push w/c
• No bowel/bladder control
• Consider level of
independence
Common Manifestations/Complications
• T1-6 = full use of upper
extremity
• Transfer self
• Drive car with hand controls
and do ADL’s
• No bowel/bladder control
Immediate Care
Emergency Care at Scene, ED & ICU
• MOI
• Transport with cervical
collar (LOG ROLL)
• Assess ABC’s
– Suction PRN/Airway
– O2
– BVM/Intubate
• IV x2 large bore
• Foley
• CMS
Diagnostic Studies for SCI
• X-ray of spinal column
• CT with and/or without
contrast (depends on MOI)
• MRI
• Lab work
• Blood gases
Therapeutic Interventions
• Medications
• IV methylprednisolone (Solu-Medrol) within 8 hrs to
decrease cord edema
• Controversial!!
Therapeutic Interventions
• Medications
• To control or to prevent complications of SCI and
immobility:
– Vasopressors to maintain perfusion
– Histamine H2 blockers to prevent stress ulcers
– Anticoagulants
– Stool softeners
– Antispasmodics
Therapeutic
Interventions
Stabilization/
Immobilization
Traction
Gardner-wells tongs
Halo
Casts
Splints
Collars
Braces
Therapeutic Interventions
Surgery for SCI
• Manipulation to correct
dislocation or to unlock
vertebrae
• Decompression
laminectomy
• Spinal fusion
• Wiring or rods to hold
vertebrae together
Nursing Management
Assessment
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•
•
•
HEALTH HISTORY (SAMPLE)
Description of how and when injury occurred (MOI)
Other illnesses or disease processes
Ability to move, breathe, and associated injury such
as a head injury, fractures
Nursing Management
Assessment
PHYSICAL EXAM
• LOC and pupils
– may have indirect SCI from head injury
• Respiratory status
– phrenic nerve (diaphragm) and intercostals; lung
sounds
• Vital signs
• Motor
• Sensory
• Bowel and bladder function
Nursing Management
Assessment
Motor Assessment
Upper Extremity
 Movement, strength and symmetry
 Hand grips
 Flex and extend arm at elbow
 with and without resistance
Nursing Management
Assessment
Motor Assessment
Lower Extremity
• Flex and extend leg at knee
– with and without resistance
• Planter and dorsi flexion of
foot
• Assess for Clonus
Nursing Management
Assessment
Sensory assessment
• With the sharp and dull
ends of a paperclip have the
individual, with their eyes
closed identify
• Use the dermatome as
reference to identify level
• C6 thumb; T4 nipple; T10
naval
Nursing Problems/Interventions
•
•
•
•
•
•
•
1.Impaired mobility
2.Impaired gas exchange
3. Impaired skin integrity
4. Constipation
5. Impaired urinary elimination
6. Risk for autonomic dysreflexia
7. Ineffective coping
1. Impaired Physical Mobility
• Log roll as a single unit; provide assistance as
needed to keep alignment; teach patient
• Care traction, collars, splints, braces, assistive
devices for ADL’s
• Flaccid paralysis- use high top tennis shoes or
splints to prevent contractures. Remove at
least every 2 hrs for ROM (active ROM best)
1. Impaired Physical Mobility
• Spastic Paralysis
– Prevent spasms by avoiding: sudden movements
or jarring of the bed; internal stimulus (full
bladder/skin breakdown; use of footboard; staying
in one position too long; fatigue)
– Treat spasms by decreasing causes; hot or cold
packs; passive stretching; antispasmodic
medications
• Assess skin breakdown & thrombophlebitis; remove
TED hose at least every shift
1. Impaired Physical Mobility
• Prevent/treat orthostatic hypotension
– Abdominal binder, calf compressors, TED hose
when individual gets up
– Assess BP, especially when rising
– Teach use of transfer board
– Assist Physical Therapy with tilt table as individual
gradually gets use to being in an upright position
2. Impaired Gas Exchange
• Phrenic nerve (C3-5) controls the diaphragm
bilaterally. If nerve is nonfunctioning then
individual is ventilator dependent.
• Thoracic nerves control the intercostals
muscles for breathing and abdominal muscles
aide in breathing and coughing
2. Impaired Gas Exchange
• Respiratory rate, rhythm, depth, breath sounds,
respiratory effort, ABG’s, O2 saturation
• Signs of impending extension of SCI up cord to
phrenic nerve level (C3-5)
• Need for ventilatory assistance (tracheotomy,
ventilator )
• Quad cough (assistive cough) as needed
3. Impaired Skin Integrity
• Change position frequently
• Protection from extremes in temperature
• Inspect skin at least 2x/day especially over boney
prominences
• Avoid shearing and friction to soft tissue with
transfers
• Removal of TED hose every 8 hours/SCDs
• Nutritional status
4. Constipation
• Bowels rely more on bulk than on nerves
• Stimulate bowels at the same time each
day. Best after a meal when normal
peristalsis occurs
• Individual may progress from Dulcolax
suppository to glycerin then to gloved
finger for digital stimulation
• Assess bowel sounds prior to giving food
for the first time– paralytic ileus!
5. Impaired Urinary Elimination
 Flaccid bladder (lower motor neuron lesion)
- No reflex from S2,3,4
- Automatic empting of bladder
- Urine fills the bladder and dribbles out
- Need Foley or freq intermittent self catheterization
 Spastic bladder (upper motor neuron lesion)
- Reflex arc but no connection to or from brain
- Reflex fires at will
- Bladder training- trigger points to stimulate empting; self
catheterization
5. Impaired Urinary Elimination
•
•
•
•
Use bladder scan to see amount of urine in bladder
Goal = residual <100ml/20% bladder capacity
Some individuals may need suprapubic catheter
Assess effectiveness of medication
– Urecholine to stimulate bladder contraction
– Urinary antiseptic
6. Risk for Autonomic Dysreflexia
• SCI above T6
• Results in loss of normal compensatory
mechanisms when sympathetic nervous system is
stimulated
• Life threatening!
• If goes unchecked BP can result in cerebral
hemorrhage
• Vasodilatation symptoms above SCI
• Vasoconstriction symptoms below SCI
7. Ineffective Coping/Grief and Depression
• Assess thoughts on ‘quality of life’; body
image; role changes
• Physical and psychological support
• Most common SCI is 15-30 year old males and
generally risk takers
– This greatly affects their perception of life and
rehabilitation
7. Ineffective Coping/Sexuality
Male
• UMN lesion
– reflexogenic (S2,3,4) erections
• LMN lesion
– psychogenic erections
(psychological stimulation)
• Ejaculation/fertility may be
affected
Female
• Hormones more than
nerves regarding fertility
• C-section because of chance
for autonomic dysreflexia
during labor
• Lack of
sensation/movement
affects sexual performance
7. Ineffective Coping/Sexuality
• Assess readiness/knowledge/your ability to teach
• Use proper terminology
• Suggestions:
–
–
–
–
–
empty bladder before sex
withhold fluids and antispasmodics
certain positions may increase spasms
explore new erogenous zones
penile implants
• Refer to specially trained counselor
Home Care
• Assess psychological & physiological resources
• Need for rehabilitation (in-house or out
patient)
• Need for community resources
• Home assessment
What’s new in SCI treatment?
 Superman breather
 Superman Breather
• Kevin Everett
 Hypothermia for SCI
 Travis Roy
 11 Seconds
 Travis Roy B.U.
 Stem Cell treatment for SCI
 Lipitor for SCI
CASE STUDY
• Patient Profile
– Mr. Porter is a 19-year-old man with a spinal cord
injury (paraplegic), status post gunshot wound to
the lumbar spine. His accident was 4 months ago,
and he is in the rehabilitation unit.
• Subjective Data
– States he is depressed and “is getting used to the idea of not walking
again”
• Objective Data
• Physical Examination
• Vital signs: supine blood pressure 120/68, sitting blood pressure 114/62,
pulse 68, temperature 99º F, respirations 16
• Apical pulse: 69
• Slight edema bilateral lower extremities
• Urine dark yellow in drainage bag
• Last bowel movement yesterday
• Coccyx with 2 cm red area
• Right heel with 1 cm red area
• Full passive range of motion in the bilateral lower extremities without
crepitation
• Full active range of motion in the bilateral upper extremities without
crepitation
• No sensation in bilateral lower extremities, normal sensation bilateral
upper extremities
•
•
•
•
Diagnostic Studies
White blood cells: 9500/µl
Hemoglobin: 16 g/dl
Hematocrit: 45%
Critical Thinking Questions
– What is the primary nursing concern for this
patient?
– What nursing interventions are appropriate for
impaired skin integrity?
– Based on all of the assessment data, what are
other nursing priorities?
– What are appropriate nursing diagnoses for a
patient with paraplegia?
Herniated Discs
Herniated Disc
 Herniated nucleus pulposus, (HNP) slipped disc,
ruptured disc
 HNP- annulus becomes weakened/torn and the
nucleus pulposus herniates through it
Risk Factors
 Standing erect
 Aging changes
 Poor body mechanics
 Overweight
 Trauma
Common Manifestations/Complications
• HNP compresses
– Spinal nerve (sensory or
motor component) as it
leaves the spinal cord
– Or the cord itself (the
white tracts within the
cord)
• rare
Common Manifestations/Complications
 Sensory root or nerve usually affected
 pain, parenthesis, or loss of sensation
 Motor root or nerve may be affected
 paresis or paralysis
 Manifestations
 depend on what nerve root, spinal nerve is being
compressed– which dermatomes
 Radiculopathy
 pathology of the nerve root
Common Manifestations/Complications
Lumbar HNP
 Most common site for HNP
 L4-5 disc- the 5th lumbar nerve root
 posterior sensory nerve or root compressed
 Classic symptoms
 low back / sciatica pain
 pain increases with increase in intrathoracic pressure
 Herniated disc L4-L5
Other Symptoms Lumbar HNP
•
•
•
•
•
•
•
•
Postural changes
Urinary/male sexual function changes
Paresis or paralysis
Foot drop
Paresthesias
Numbness
Muscle spasms
Absent cord reflexes
Common Manifestations/Complications
Cervical HNP
C5-C6 disc- affects the 6th cervical nerve root
• Pain- neck, shoulder, anterior upper arm to
thumb
• Absent/diminished reflexes to the arm
• Motor changes- paresis or paralysis
• Sensory- paresthesias or pain
• Muscle spasms
Therapeutic Interventions
Diagnostic Tests
• X-ray
– identify deformities
and narrowing of
disk space
•
•
•
•
CT
MRI
Myelogram
Nerve conduction
studies (EMG)
– detect electrical
activity of skeletal
muscles
Treatment: Conservative
 Bed rest with firm mattress
 log roll
 side lying position with knees bent and pillow
between legs to support legs
 Avoid flexion of the spine
 brace/corset, cervical collar to provide support
 Medications
 non-narcotic analgesics, anti-inflammatory, muscle
relaxants, antispasmodics and tranquilizers
Treatment: Conservative
 Heat/cold therapy to decrease muscle spasms
 Break the pain-spasm-pain cycle
 Ultrasound, massage, relaxation techniques
 Progressive mobilization with approved exercise
program –includes abdominal/thigh strengthening
 Teaching good body mechanics
 Weight loss
 TENS unit
Treatment: Surgery
• Laminectomy
– removal of a portion of the lamina to relieve pressure
and to get to the herniated nucleus pulposus that is
protruding out
• Herniated disc repair
• Foraminotomy
– enlargement of the bony overgrowth at the opening
which is compressing the nerve
• Microdiskectomy
– Use of electron microscope through a small incision to
remove a portion of the HNP that is displaced
• Anterior cervical fusion
– If cervical HNP, usually use the anterior approach in the
neck
Treatment: Surgery
• Spinal fusion
• removes most of the disc and replaces it with
bone usually from the patient iliac crest
• fusion also with rods, pins, synthetic protein
• flexibility is lost at the site- requires longer
hospital stay
• Artificial Disc
• combination of metal and plastic
• attached to vertebrae above and below
Prevention of HNP
• Back school approach
– Causes of HNP
– Learn how to prevent
– Good body mechanics
– Exercises to strengthen leg and abdominal
muscles
• Change in life-style or occupation
Nursing Assessment Specific to HNP
Health History
• Assess for risk factors
• The cumulative effect of standing erect and daily
stress
• Aging changes in disc/ligaments
• Poor body mechanics
• Overweight
• Trauma
• Employment
• History of pain and other neuro changes
Nursing Assessment Specific to HNP
Physical Exam
• Use similar methods to assess as utilized SCI
• Muscle strength and coordination
• Sensation
– sharp/dull of paperclip using dermatome as
reference
• Pain evaluation- pain scale
• Pre/Post-op assessment
Post-Op Assessment for HNP
• Sensory/motor assessment
– be careful not to injure op site
• Assess for CSF drainage or bleeding from op site
• Encourage turn (log roll, cough, deep breath)
• Assess for postural hypotension
– especially if patient was on bed rest for
several days/weeks prior to surgery
Post-op Assessment for HNP
• If Anterior Cervical
– Assess injury to the carotid, esophagus, trachea,
laryngeal nerve (speech- hoarseness)
– Assess respiration, neck size, swallowing and
speech
• If Post-Op Lumbar
– Assess bowels sounds, voiding
– Minimize stress of post-op site- flat with pillow
between knees, log roll, etc
Nursing Problems/Interventions
1. Acute Pain
 Post surgery the individual may have similar pain as preop due to lack of resiliency of the spinal nerves to
‘bounce’ back quickly
 Donor site (illiac crest) may cause more pain than
laminectomy
 Individual may be in a pain-spasm-pain cycle, therefore
may need both antispasmodic as well as analgesic
2. Chronic Pain
• Surgery may not relieve pain
• Consider nonpharmalogical methods
to control pain
• Pain clinic
Spinal Cord Tumors
Spinal Cord Tumors
• CNS is made up of neural tissue and
support tissue
• These tissues undergo changes and
result in spinal cord tumors
• Blood vessels and bone also can be
part of the tumor
Classification by origin
 Primary
 originating in the spinal cord or meninges
 Secondary
 metastases from other parts of the body
 Most spinal cord tumors are found in the thoracic
region
 Spinal cord tumors can compress (benign), invade
the neural tissue, or cause ischemia to the area
because of vascular obstruction
Common Manifestations/Complications
• Symptoms depend on the anatomical level of the
spinal column, the anatomical location, the type
of tumor and the spinal nerves affected
• Pain that is not relieved by bed rest is the most
common presenting symptom
• Other symptoms are similar to those found with
HNP or spinal cord injury- sensory or motor
Common Manifestations/Complications
• Manifestations of thoracic cord tumor
– Paresis & spasticity of one leg then the other
– Pain back & chest, not relieved by bed rest
– Sensory changes
– Babinski reflex
– Bowel (ileus); bladder dysfunction (UMN in type)
Therapeutic Interventions
• Diagnostic tests include
– X-ray of the spinal column
– Myelogram
– Lumbar puncture with CSF analysis
Therapeutic Interventions
• Medications for spinal tumors
– Control pain
• narcotic analgesics, epidural catheter, PCA, NSAID’s
– Reduce cord edema and tumor size
• steroids- high dose Dexamethasone
Therapeutic Interventions
• Surgery for spinal cord tumors
– Laminectomy to remove or to decrease the size
(decompression laminectomy) of the spinal cord
tumor
– Spinal fusion or the insertion of rods if several
vertebra involved and the column is unstable
• Radiation to reduce size and control pain
Nursing Assessment
• Health history
– Pain, motor and sensory changes, bowel and
bladder changes, Babinski reflex
• Physical exam
– Similar to physical assessment for HNP
Nursing Problems/Interventions
• 1. Anxiety
– Metatastic tumor vs benign spinal cord tumor
– Education and support system
• 2. Risk for constipation
– From spinal cord compression, narcotics, bed rest
– Adjust fluid and diet
Nursing Problems/Interventions
 3. Impaired physical mobility
– From bed rest and motor involvement
– Basic nursing- ROM, etc
 4. Acute pain
– From compression or invasion of tumor
– Assess and treat
 5. Sexual dysfunction
– Male sacral reflex arc (S 2,3,4) interference
– Similar care as discussed with SCI
Nursing Problems/Interventions
• 6. Urinary retention
– Reflex arc (S2,3,4) interference can cause
neurogenic bladder as discussed with SCI
• 7. Home care
– Rehabilitation
– Home evaluation
– Support groups
A 30-year-old was admitted to the progressive
care unit with a C5 fracture from a motorcycle
accident. Which of the following assessments
would take priority?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The patient’s feelings about the injury
While in the ED, a patient with a C8 tetraplegia
develops a blood pressure of 80/40, pulse 48,
and RR of 18. The nurse suspects which of the
following conditions?
1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism
A 22-year-old patient with quadriplegia is
apprehensive and flushed, with a blood pressure
of 210/100 and a heart rate of 50 bpm. Which of
the following nursing interventions should be
done first?
1. Place the client flat in bed
2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 45-90
degrees
A patient with a cervical spine injury has
Gardner-Wells tongs inserted for which of the
following reasons?
1. To hasten wound healing
2. To immobilize the surgical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together
A patient has a cervical spine injury at the level of
C5. Which of the following conditions would the
nurse anticipate during the acute phase?
1. Absent corneal reflex
2. Decerebrate posturing
3. Movement of only the right or left half of the body
4. The need for mechanical ventilation
The nurse is evaluating neurological signs of the
male patient in spinal shock following spinal cord
injury. Which of the following observations by the
nurse indicates that spinal shock persists?
1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinski’s reflex
4. Reflex emptying of the bladder
Your T1 spinal cord injured patient complains of
a headache. You should
1. Give him prn Tylenol
2. Disimpact his bowels
3. Call the doctor
4. Take his blood pressure
Your patient has a malignant metastatic lesion at
T8 and is in for palliative radiation. What is
your main goal with this patient?
1. Teach patient self catheterization
2. Ensure patient receives pain medication as
needed
3. Encourage patient to discuss fears
4. Ambulate twice a shift