A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right,
absent bowel sounds, zero urine output, and palpation of a distended bladder. The nurse realizes that these findings are consistent with which condition?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
Correct Answer: 2
Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord. As a result of the injury, sympathetic function is interrupted and parasympathetic function is unopposed. This condition is characterized by flaccid paralysis, loss of skin reflexes and deep tendon reflexes, and loss of all sensations below the level of injury. There is loss of urinary bladder tone. The autonomic dysfunction results in hypotension. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in a spine-injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.
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