CRITICAL THINKING EXERCISE

Case #1 Neurologic Trauma

A 28-year-old-white man was involved in a motor vehicle crash. He is brought to the
emergency room on a backboard with a neck brace in place. The vehicle had been
involved in a head-on crash with a telephone pole, and the speedometer was stuck
on 65 miles per hour. The driver was wearing a seatbelt and his airbag has
deployed. He had only minor injuries and was taken to another local emergency
department.
The passenger did not have a seatbelt on and was thrown out of the car on impact
when the passenger door flew open. He did have a brief (<5 minutes) loss of
consciousness, but was awake, alert and oriented when the ambulance arrived at
the scene. The patient stated that as soon as he woke up he realized that he could
not move anything except his head. He complained of severe pain in his neck at the
level of C5. Two intravenous lines were started at the scene, and the patient
received 3 L of fluid before arrival in the emergency department. It has been less
than two hours since the patient was injured.
Significant findings on your assessment are that the patient is alert, but sleepy. He
is complaining of headache and neck pain at the level of C5. His pupils are equal
and react equally to light. The patient is unable to move his extremities or to shrug
his shoulders. He can feel pain and pressure applied to his face and upper neck but
nothing below that. You note that his abdomen is moving up and down with each
breath and working hard to breathe. He has no discernible chest wall movement.
His temperature is 36 degrees Celsius, and his extremities feel cold. His blood
pressure is 80/50 mmHg, his pulse is 443 and his respirations are 28 and labored. A
pulse oximeter is applied and the oxygen saturation is 92% on a 40% face mask.
The patient is placed on a cardiac monitor, and cervical spine films and blood work,
including arterial blood gases, have been ordered. Intravenous fluids have been
decrease to 50ml per hour in each intravenous line (total 100ml per hour). The
patient remains on the backboard with the cervical collar in place.
1. At this point in the care of this patient, what is your most important
concern?
At this point of care, the most important concern was the respiratory function
of the patient. Assessments have showed that his abdomen is moving up and
down with each breath and working hard to breathe and has no discernible
chest wall movement. These findings indicate a great risk for ineffective
breathing pattern of the patient due to impairment of innervation of the
diaphragm and loss of intercostal muscle function due to possible lesions on
the spinal cord (at or above C5) (Doenges, Moorhouse, & Murr, 2010). In high
cervical cord injury, acute respiratory failure is the leading cause of death
(Smeltzer, Bare, Hinkle, & Cheever, 2010). Other priorities are: Prevention of

further injury to the SC, Monitoring of Neurological Vital signs and

Cardiovascular functions.
2. Discuss the rationale for the interventions that have been ordered to
this point, including the cardiac monitor, arterial blood gas, and the
decrease in intravenous fluids?
a. 2 IV lines started- Insertion of 2 IV lines using large-bore cannulas (14-16
gauge) for fluid resuscitation.
b. Pulse oximeter- to monitor oxygenation status of the patient.
c. Cardiac monitor- to monitor cardiovascular function and presence of
dysrhythmias.
d. Cervical spine films- reveal the extent of fracture, the most important
initial diagnostic tool.
e. ABG-monitors the effectiveness of gas exchange and ventilator efforts.
Abnormalities may be present, depending on level of SCI and limitation of
chest expansion and muscle involvement (Doenges, Moorhouse, & Murr,
2010).
f. IVF decreased- Copious intravenous fluids infused into the possible spinally shocked
patient will lead to pooling of the fluid in the lower limbs or lungs, leading to gross
pulmonary edema . Unless major blood loss is established, fluid should be replaced
judiciously. (Hughes, 2003)

g. Backboard with cervical collar- The patient must always be maintained in

an extended position. No part of the body should be twisted or turned.
Any twisting movement may irreversibly damage the spinal cord by
causing a bony fragment of the vertebra to cut into, crush, or sever the
cord completely (Smeltzer, Bare, Hinkle, & Cheever, 2010).
3. It is less than 2 hours since the injury and loss of function, so high-dose
methylprednisolone is ordered to be started in the emergency department.
What dose would the nurse plan to administer?
-Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body
weight over fifteen minutes within eight hours of closed spinal cord injury. (H, et al., 2002)

The patient is transferred to the CT scanner for CT myelogram, which shows

fracture dislocation of the C5 vertebra, a pedicle fracture of C6, and a laminar
fracture of C7. With that amount of damage to the vertebral column, the surgery is
performed, including an anterior cervical fusion from C3 to T1. After surgery the
patient is transferred to the ICU for management and care.
On admission, the patients vital signs are as follows: BP 90/50, HR 40, RR 24. The
patient is awake and looks anxious. You are to start a dobutamine drip to maintain
mean arterial pressure of 85 mmHg.
4. What dose of methylprednisolone are you maintaining at this point? When
will you discontinue methylprednisolone?
-Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body
weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes
later by an infusion of 5.4 mg per kilogram of body weight per hour for 23 hours. (H, et al., 2002).

Thus, the infusion rate at this point is 5.4mg/kg body wt. that will be infused for 23 hours. With a
total infusion of methylprednisolone for 24 hours only, then discontinue the infusion.

5. Describe your assessment strategy for monitoring the respiratory status of

this patient. Provide rationales.
a. Note clients level of injury when assessing respiratory function. Note
presence or absence of spontaneous effort and quality of respirationslabored, using accessory muscles.
R- C1 to C3 injuriesresult in complete loss of respiratory function. Injuries
at C4 or C5 can result invariable loss of respiratory function, depending on
phrenic nerve involvement and diaphragmatic function, but generally
cause decreased vital respiratory muscle function is preserved; however,
weakness and impairment of intercostal muscles may reduce
effectiveness of cough, ability to sigh, and deep breaths.
b. Auscultate breath sounds, Note areas of absent or decreased breath
sounds or development of adventitious sounds such as rhonchi.
R-Hypoventilation is common and leads to accumulation of secretions,
atelectasis, and pneumonia.
c. Observe skin color for cyanosis or duskiness
-Skin color may reveal impending respiratory failure and need for
immediate medical evaluation and intervention.
d. Measure and graph VC, VT, and inspiratory force
R- Pulmonary function tests determine level of respiratory muscle
function. Serial measurements may predict impending respi. Failure.
e. Measure and graph ABG and pulse oximetry
R- Documents status of ventilation and oxygenation and identifies
respiratory problems such as hypoventilation, hypoxia, acidosis among
others.
6. What drugs would you have t the bedside to treat symptomatic bradycardia
in this patient?
vPharmacologic therapy for bradycardia after a cervical spinal cord injury
includes intermittent atropine 0.4-1 mg. If
atropine therapy fails, theophylline (200 mg IV x1 then 100-200 mg po q8h)
or aminophylline (300 mg IV x1 then 5
mg/kg/h, then switched to oral theophylline) can be used to increase heart
rate. Propantheline 30 mg po q4h can be
considered, but the availability of the drug and its numerous side effects
make it less of an attractive option (Rhagavendron, 2006).
7. Three major nursing diagnoses during the emergency and ICU phases of care
are alteration in temperature regulation related to disruption of hypothalamic
control, potential for injury and venostasis, and alteration in bowel and
bladder function related to muscle paralysis and spinal shock. What are the
nursing interventions related to these diagnosis during this phase of care?
a. alteration in temperature regulation related to disruption of hypothalamic
control
b. potential for injury and venostasis

c. alteration in bowel and bladder function related to muscle paralysis and

spinal shock.909
8. How will psychological concerns of this patient be handled during the critical
care phase of care?

Case #2 Burn
Mr. Bowman is a 32-year-old white man who has sustained a 58% TBSA burn as a
result of an indoor explosion in a sawmill where he is employed. Mr. Bowman is well
nourished, slender man at 72 kilograms, and relatively healthy until this event. He
does not smoke, but reports drinking a case of beer a week for the last 5 years. He
has never been seriously ill or had any operations. Mr. Bowman is married and the
father of two children. His family history indicates no hypertension; diabetes; or
heart, lung, or kidney disease.
Mr Bowman was airlifted to the regional burn trauma center about four hours after
the explosion. On admission to the burn unit, initial assessment revealed that he
had received 58% TBSA burn. He was observed to have full thickness burns on his
face, both arms (circumferential), the dorsal surfaces of both hands, and the
posterior surfaces of both thighs. These full thickness burns account for 40% of the
TBSA. The remaining 18% of the TBSA burned demonstrates partial thickness burns.
These include the posterior head and neck, the buttocks, and the palms, and the
anterior areas of his thighs.
Using the Baxter Parkland formula, Compute for the fluid resuscitation for Mr.
Bowman.

Bibliography
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans:
Guidelines for individualizing Client Care across the Life Span (8th Edition
ed.). Philadelphia: F.A Davis Company.
H, H., DE, C., MF, D., DH, F., RJ, F., DM, I., et al. (2002, August 29). High-dose
methylprednisolone for acute closed spinal cord injury--only a treatment
option. Canadian Journal of Neurological Sciences, pp. 227-235.
Hughes, R. (2003, December 16). The management of patients with spinal cord
injury. Retrieved from www.nursingtimes.net:
http://www.nursingtimes.net/nursing-practice/clinical-zones/painmanagement/the-management-of-patients-with-spinal-cordinjury/205151.article

Rhagavendron, K. (2006). Residency Program Drug Information Response

Documentation. Medline.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner &
Suddarth's Textbook of Medical-surgical Nursing. Philadelpia: Lippincott
Williams & Wilkins.