Medical Surgical Spinal Cord Injury #4

Question

A nurse is caring for a client with a C5 spinal injury. Which action is most important for a client with injury to the C5 spinal cord?

Answers

  1. Encouraging the use of an incentive spirometer
    • Rationale:

      This answer is not correct because although it is very important, it is not the most important of the answers listed. Incentive spirometry promotes deep breathing, which helps diaphragm function and clears the lungs to prevent infection.

  2. Monitor for signs of infection
    • Rationale:

      This answer is not correct because it is not the most important. However, monitoring for signs of respiratory infection is imperative due to the client with an C5 injury being unable to properly clear the lungs of secretions, which can lead to infection.

  3. Monitor client's respiratory status
    • Rationale:

      This answer is correct because monitoring the client’s respiratory status will alert the nurse to changes that may indicate atelectasis or infection. An injury to C5 will sometimes require endotracheal intubation and mechanical ventilation. However, it may involve diaphragm weakness, but with the ability to breathe independently.

  4. Apply an abdominal binder
    • Rationale:

      This answer is not correct because although the utilization of an abdominal binder will support the weak abdominal muscles, it is not a priority. The abdominal muscles assist the diaphragm for breathing.

Overview

The client with a C5 injury will have weak diaphragm muscles and be unable to take deep breaths and cough. Monitoring respiratory status will help the nurse assess for changes that indicate infection.

Explanation

Learning Outcomes

Damage to the C5 spinal cord results in quadriplegia. Quadriplegia is paralysis involving all four extremities. The client with this injury may also have diaphragm involvement, since the C5 nerves innervate a section of the diaphragm. The diaphragm is one of the muscles for respiration. The client with the C5 injury may be unable to take deep breaths and cough. Deep breathing and coughing brings oxygen into your lungs and clears secretions that may cause respiratory infection. Monitoring rate, depth and effort, auscultating the breath sounds, monitoring oxygen saturation and arterial blood gases are all important ways to assess respiratory status. Monitoring detects changes early so that full respiratory decompensation can be avoided.

Test Taking Tip

Know the spinal cords and their functions and always remember airway and breathing are first priorities.

Video Rationale