A client with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock
The nurse includes which of the following interventions in the client's plan of care to best address this issue? Select all that apply. 1. Utilize abdominal binder and thigh-high compression stockings.
2. Administer vasoactive agents and atropine as ordered.
3. Strictly monitor and document intake and output.
4. Administer anticoagulant medication as ordered.
5. Assess color, temperature, and size of extremities.
1. Utilize abdominal binder and thigh-high compression stockings.
2. Administer vasoactive agents and atropine as ordered.
3. Strictly monitor and document intake and output.
Rationale: Utilize abdominal binder and thigh-high compression stockings. Utilization of abdominal binder and thigh high compression stockings will help venous blood return and minimize blood pooling in the abdomen and lower extremities. Administer vasoactive agents and atropine as ordered. Administer vasoactive agents and atropine as ordered to ensure adequate blood pressure, heart rate, and cardiac output. Strictly monitor and document intake and output. Monitor intake and output and replace intravascular volume to ensure adequate fluid status. Administer anticoagulant medication as ordered. Administering anticoagulant as ordered is for the prevention of peripheral DVT. Assess color, temperature, and size of extremities. Assessing color, temperature, and size of extremities enables early detection and prompt treatment of DVT.
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