Mr. White is a 17-year-old male who was injured in a snowboarding accident 3 weeks ago. He sustained a vertebral fracture and complete spinal cord injury at T7. His fracture has been stabilized with rods and screws. The plan is for him to be discharged home in 3 days with home health and family care. The CNA reports to you that the bath has been completed, there was no BM or incontinence of urine. However, Mr. White's blood pressure has risen to 189/100 with a heart rate of 56. You immediately go to the room to check on Mr. White.
What things should you assess in order to determine the problem? (Select all that apply, one, some or all)

Rationale:

A. Mr. Snowden was submerged in icy water, which puts him at high risk for hypothermia. Hypothermia can worsen coagulopathy, impair cardiac function, and affect drug metabolism. Maintaining normothermia through warming blankets, warmed IV fluids, and environmental temperature control is essential for stabilization and to prevent secondary complications.

B. There is no indication of a urinary tract infection in the current assessment. Administering antibiotics for a UTI would be unnecessary and not a priority in the acute stabilization phase. Priority interventions should focus on immediate life-threatening issues and injuries sustained from the accident.

C. With a complete T10 spinal cord injury, frequent neurologic assessments are vital to monitor for changes in motor function, sensation, and reflexes above the level of injury. Hourly checks help detect complications such as autonomic dysreflexia, spinal shock, or evolving cord edema. Monitoring the Glasgow Coma Scale (even with intubation), voluntary movements in extremities, and sensory response is part of these assessments.

D. Spinal precautions are critical due to the complete T10 injury. The log-roll technique maintains spinal alignment and prevents further cord damage while turning, repositioning, or performing hygiene care. All staff must coordinate movements to prevent rotation or flexion of the spine.

E. The large abrasion/laceration on the scalp could lead to significant bleeding, infection, or indicate underlying skull fracture. Assessment includes checking for active bleeding, signs of hematoma or swelling, neuro changes, and proper wound care. This is important to prevent secondary complications and infection.

F. Mr. Snowden’s vital signs (heart rate 72 bpm, respiratory rate 16, oxygen saturation 99%) are currently stable. There is no evidence of hypovolemia or shock, so IV fluid bolus is not immediately indicated. Fluids may be considered later if hypotension develops or in response to lab values.

G. Collecting accurate information about the accident helps determine timing of submersion, duration of CPR, previous medical conditions, medications, allergies, and baseline neurologic function. This informs ongoing care decisions, prognostication, and potential complications such as hypoxic brain injury or organ damage.

H. Mr. Snowden is intubated and fully dependent on mechanical ventilation. Continuous monitoring of airway patency, ventilator settings, oxygenation, and tidal volumes is a life-saving priority. Ensuring suctioning is performed as needed and preventing ventilator-associated complications (e.g., pneumonia) are also part of stabilization.

Rationale:
A. A yellow (delayed) tag is appropriate because, although the injury is serious, the presence of distal pulses indicates adequate perfusion and no immediate life-threatening compromise. Treatment can be delayed without immediate risk to life.

B. This client is critically injured with a high risk of hemorrhagic shock and airway compromise. He requires immediate intervention and should be tagged red (immediate), not yellow.

C. Severe chest pain may indicate a life-threatening condition such as myocardial infarction or internal thoracic injury. Red tags are assigned to clients who require immediate care to survive.

D. Respiratory distress and chest trauma suggest potential life-threatening injury (e.g., pulmonary contusion). This client should be classified as red (immediate), not green (minor).

E. A scalp laceration, while it may bleed significantly, is generally not life-threatening if controlled. This client would more appropriately receive a green (minor) or possibly yellow tag, not black (expectant/deceased).

F. Full-thickness burns are severe, potentially life-threatening injuries that require urgent or emergent care depending on extent. This client would not be classified as green (minor) and would more likely be red or possibly black if injuries are unsurvivable.