A client with a spinal cord injury at the T4 level is admitted to the hospital. Which of the following is the most important nursing intervention during the first 48 hours after the injury?
A) Monitor for signs of autonomic dysreflexia.
B) Administer high-dose methylprednisolone.
C) Position the client in a high Fowler’s position.
D) Monitor respiratory function.
The Correct answer and Explanation is:
Correct Answer:
D) Monitor respiratory function.
Explanation:
The most crucial nursing intervention in the first 48 hours after a spinal cord injury, especially at the T4 level, is to monitor respiratory function closely. This is because spinal cord injuries at or above the T6 level can disrupt the nervous control of the muscles involved in breathing, particularly the intercostal muscles, which are vital for effective respiration.
The T4 level is significant because the spinal nerves here control the muscles of the chest, which play an important role in breathing. A spinal cord injury at this level can compromise the client’s ability to breathe, increasing the risk of respiratory failure. Additionally, swelling or edema around the injury site can ascend, potentially affecting higher levels of the spinal cord, including those that control the diaphragm (C3-C5). Therefore, monitoring respiratory function is critical to detect early signs of respiratory distress, hypoventilation, or failure.
Autonomic dysreflexia (Option A) is a life-threatening condition that can occur in clients with spinal cord injuries at or above the T6 level, but it is more likely to develop later in the recovery process rather than in the first 48 hours.
Administering high-dose methylprednisolone (Option B) was once a common practice to reduce inflammation around the spinal cord injury. However, its use has become controversial, and it is no longer universally recommended due to potential side effects.
Positioning the client in a high Fowler’s position (Option C) may be appropriate for managing blood pressure or breathing in some cases but is not as universally critical as respiratory monitoring in the immediate post-injury phase.
In summary, the primary concern in the acute phase of a spinal cord injury is ensuring adequate respiratory function to prevent respiratory failure, which is why option D is the most important nursing intervention during this period.