Question

A client is on the neurological unit after a sports injury resulting in a thoracic fracture. The nurse's assessment reveals an intact halo device, flushing of the face and upper chest area, goose bumps, and a stuffy nose. What additional assessment would be most important at this time? A. Breath sounds B. Deep tendon reflexes C. Blood pressure D. Bowel sounds

Short answer

Answer: Monitoring blood pressure (option C) is the most important additional assessment. The symptoms described indicate the possibility of autonomic dysreflexia, which can lead to dangerously high blood pressure and requires immediate attention.

Step-by-step solution

Understand the symptoms and complications related to thoracic fracture

A thoracic fracture can lead to various complications, including respiratory and cardiovascular issues, neurological damage, and impaired bowel function. The symptoms mentioned in this exercise, such as an intact halo device, flushing of the face and upper chest area, goose bumps, and a stuffy nose, could potentially be related to these complications.

Analyze each assessment option

A. Breath sounds: Assessing breath sounds is important as respiratory complications may arise due to thoracic fractures, such as pneumothorax, hemothorax, or reduced lung function. B. Deep tendon reflexes: Assessing deep tendon reflexes is crucial in evaluating the neurological status of the patient and identifying any potential neurological damage caused by the fracture. C. Blood pressure: Monitoring blood pressure is essential as it can help identify cardiovascular complications, such as hypotension or circulatory shock. The flushing and goosebumps might indicate autonomic dysreflexia which is an exaggerated reflex response which leads to high blood pressure. D. Bowel sounds: Assessing bowel sounds is relevant in identifying potential gastrointestinal complications, such as ileus or bowel obstruction. However, this may not be the primary concern based on the symptoms presented.

Determine the most important assessment

From the analysis of each option in step 2, it becomes clear that assessing blood pressure (option C) would be the most important additional assessment at this time. The symptoms described indicate the possibility of autonomic dysreflexia, which can lead to dangerously high blood pressure and requires immediate attention. Other assessments should still be performed, but blood pressure should be prioritized in this situation.

Key concepts

Autonomic Dysreflexia

Autonomic Dysreflexia is a serious medical condition often occurring in individuals with spinal cord injuries above the T6 level. It is characterized by a sudden and exaggerated reflex response that can lead to rapid increases in blood pressure. The body experiences an imbalance in the autonomic nervous system, causing reactions such as flushing of the skin, goosebumps, sweating, and a stuffy nose. Recognizing these signs is critical, as prolonged high blood pressure can lead to life-threatening complications such as a stroke or seizures.
For those preparing for the NCLEX-RN exam, it is important to understand the triggers for autonomic dysreflexia. Common triggers include bladder distention, bowel impaction, skin irritations or injuries, and even tight clothing. The key management strategy involves identifying and removing the trigger as promptly as possible to alleviate the symptoms and normalize blood pressure.
When you suspect a client is experiencing autonomic dysreflexia, immediate assessment of their blood pressure should be your priority. This will help determine the severity of the condition and guide subsequent interventions. Educating clients and their families on the symptoms and emergent nature of this condition is also essential for effective management.

Neurological Assessment

A comprehensive neurological assessment is a critical aspect of patient care, particularly for individuals with neurological impairments or after injuries like thoracic fractures. This assessment helps to determine the integrity of the nervous system and identify any changes or deterioration in the patient's condition.
Key components of a neurological assessment include evaluating the patient's level of consciousness and orientation, pupil reactions, motor and sensory abilities, and deep tendon reflexes. Each of these assessments provides valuable insights into the functioning of the central and peripheral nervous systems.
The assessment of deep tendon reflexes is particularly important in understanding the neurological status of a patient following a spinal injury. It involves tapping on tendons to elicit a reflexive response, which can reveal potential abnormalities such as hyperreflexia, indicative of upper motor neuron damage, or hyporeflexia - often associated with lower motor neuron damage. Monitoring any changes in these reflexes is crucial for planning the appropriate care and interventions.

Thoracic Fracture Complications

Thoracic fractures are serious injuries that can lead to a range of complications due to their location near vital organs and structures. Patients with thoracic fractures may experience respiratory, neurological, and even cardiovascular complications.
One important complication to be aware of is reduced lung function, due to pain or structural abnormalities from the fracture, which can lead to inadequate ventilation and respiratory distress. Therefore, assessing breath sounds is vital to identify issues such as pneumothorax or hemothorax.
Neurological complications arise when the spinal cord or nerve roots are affected by the fracture. Damage in this area can impact sensation, motor function, and reflexes below the level of injury. It is essential to regularly assess these functions to prevent deterioration and manage any developing complications effectively.
Finally, cardiovascular complications such as shock or autonomic dysreflexia, as highlighted earlier, require careful monitoring. Blood pressure assessment plays a pivotal role in detecting such issues, allowing for timely interventions that can potentially save lives.