SpineHigh yield
Bone as tissue
Bone is living tissue that is constantly broken down and rebuilt, with a hard outer layer over spongy bone and marrow, and growth plates near the ends of a child's long bones.
Why the exam cares
Bone is always being removed and replaced, and the NCLEX asks what tips that balance and what the nurse does about it. Expect questions on taking an oral bisphosphonate safely, osteoporosis prevention teaching, calcium loss during immobility, and growth plate fractures in children.
- The growth plate sits near each end of a child's long bone, between the shaft and the rounded end; on X-ray it shows as a dark (radiolucent) line.
- Osteoporosis fractures happen most often in the spine, hip, and wrist. A wrist or spine fracture is often the first sign, and lost height with a rounded upper back points to spine compression fractures.
- A bone density (DEXA) scan measures the hip and spine; a T-score of -2.5 or lower means osteoporosis.
The nurse teaches enough calcium and vitamin D (about 1,200 mg of calcium a day for women over 50 and men over 70), weight-bearing exercise like walking, no smoking, limited alcohol, and a fall-proofed home, because a hip fracture can end an older adult's independence. An oral bisphosphonate is taken first thing in the morning on an empty stomach with a full glass of plain water, and the patient stays upright and takes no food, drink, or other medicine for at least 30 minutes (60 minutes for ibandronate), because a pill that lingers can ulcerate the esophagus. New heartburn, painful swallowing, or chest pain after a dose is reported to the provider.
Bone that bears no weight is broken down, so a patient on prolonged bed rest or with a spinal cord injury releases calcium into the blood. The nurse watches for constipation, nausea, confusion, and flank pain from kidney stones, and reports a rising serum calcium. The nurse gets the patient bearing weight as early as allowed and encourages about 2 to 3 liters of fluid a day unless fluids are restricted.
A fracture through a growth plate can slow or stop growth of that bone, leaving the limb shorter or bent. A growth plate fracture can look normal on the first X-ray, so the nurse treats swelling and point tenderness near the end of a child's long bone as a possible fracture: immobilize it and make sure orthopedic follow-up happens rather than reassuring the family.
Health Promotion and MaintenancePharmacological and Parenteral TherapiesReduction of Risk Potential
SpineHigh yield
Cervical vertebrae C1–C7
The seven bones of the neck, running from C1 (the atlas) just under the skull, through C2 (the axis) with its upright peg, down to C7 at the base of the neck.
Why the exam cares
A broken or unstable neck bone can shift and injure the spinal cord in the neck, and injuries at C3 to C5 or above can stop the diaphragm. The nurse keeps the head and neck still until imaging and exam clear the spine, keeps the collar or halo secure, and catches failing breathing early.
- With the head bent forward, C7 is usually the most prominent bump in the midline at the base of the neck. If two bumps look equally prominent, the upper one is usually C7; it shifts a little as the neck bends and straightens, while T1 below it barely moves.
- The thyroid cartilage (the Adam's apple) sits in front of about C4 to C5, and the cricoid ring just below it sits in front of about C6.
- The carotid pulse is felt beside the thyroid cartilage, in the groove between the trachea and the sternocleidomastoid muscle, one side at a time.
Until imaging and exam clear the spine, the head and neck stay in line with the body: a rigid collar, a jaw thrust instead of a head tilt to open the airway, and a log roll with one person holding the head and calling the count. The nurse never lifts the patient by the shoulders or turns the trunk without the head, because movement at an unstable level can injure the cord or make an existing injury worse.
The phrenic nerve leaves the cord at C3 to C5 (see Spinal cord), and swelling after a neck injury can spread upward over the first few days, so a patient who breathes well on admission can tire later. The nurse trends respiratory rate, cough strength, and vital capacity as ordered, keeps suction and intubation equipment ready, and reports a rising rate or weakening cough right away. Oxygen saturation can stay normal until breathing is already failing, so it is not the sign to wait for.
A halo holds the neck still with pins into the skull and a vest on the chest. The nurse cleans pin sites as ordered and reports redness, drainage, or a loose pin, keeps the correct wrench taped to the vest so the front can be opened for CPR, checks the skin at the vest edges, and never uses the halo bars to lift or turn the patient.
A rigid collar presses on the back of the head, the chin and jaw, the ears, and the collarbones, and trapped moisture speeds skin breakdown. The nurse inspects and cleans under the collar and changes pads as ordered, with a second person holding the head in line whenever the collar is opened, because the neck is unprotected while the collar is off.
Physiological AdaptationSafety and Infection ControlReduction of Risk Potential
Spine
Coccyx
The coccyx, or tailbone, is a small bone of usually four fused vertebrae at the very bottom of the spine, joined to the lower tip of the sacrum.
Why the exam cares
A patient who slides down in bed or slumps in a chair puts pressure and shear on the tissue over the tailbone, so the nurse controls the head-of-bed angle, the turn schedule, and the seat cushion. After a fall onto the buttocks, the nurse checks for nerve signs before treating the pain as a simple bruise.
- Follow the midline of the sacrum down into the buttock cleft. The coccyx is the narrow segment below the sacrum, felt deeper in the cleft.
- Its tip curves forward and ends a short way behind the anus.
- Sitting upright puts weight on the ischial tuberosities. Slumping or reclining back shifts the weight onto the sacrum and coccyx.
- When charting skin damage, name the site you see: the sacrum is the broad, flat bone above and at the top of the cleft, and the coccyx is the narrow tip below it, deeper in the cleft.
With the head of the bed raised high, the patient slides toward the foot. The skin over the tailbone stays stuck to the sheet while the bone and deeper tissue move down, which stretches and kinks the deep blood vessels (shear); skin rubbing across the sheet is a separate injury (friction). The nurse keeps the head of the bed at 30 degrees or lower unless contraindicated, raises the knees slightly to stop sliding, repositions at least every 2 hours or per facility policy, and uses a lift sheet with help instead of dragging the patient up. In a chair, the nurse uses a pressure-redistributing cushion, never a donut or ring, because a ring presses hard on the tissue it touches and cuts blood flow to the tissue inside it.
A backward fall onto the buttocks usually bruises the coccyx; a fracture is less common, and both cause pain on sitting and when the tailbone is pressed. The nurse checks for other injuries and asks about numbness or weakness in the legs, numbness between the legs, and new bladder or bowel changes, and reports any of these to the provider right away because they point to nerve or spinal injury. For an ordinary bruise, the nurse teaches the patient to sit on a wedge or cut-out cushion, lean forward when seated, take pain medicine as ordered, and use a stool softener as ordered or recommended because straining hurts, and warns that sitting may hurt for several weeks.
Basic Care and ComfortReduction of Risk Potential
SpineHigh yield
Lumbar vertebrae L1–L5
The five large bones of the low back, between the rib cage and the sacrum, which are the biggest vertebrae and carry the most body weight.
Why the exam cares
In an adult the spinal cord ends at about L1 to L2, so a needle placed lower, at L3–L4 or L4–L5, enters spinal fluid and floating nerve roots without hitting the cord. The nurse positions the patient curled forward to open these spaces, reports warning signs before the procedure, and watches for the problems that follow it.
- A line across the tops of the two iliac crests crosses the spine at about L4; the nurse uses it to find the L3–L4 and L4–L5 spaces.
- L5 is the last vertebra above the sacrum, at the bottom of the low-back curve.
- The spaces are easier to feel when the patient curls forward, which spreads the spinous processes apart.
Before the tap, the nurse reports signs of raised intracranial pressure, such as headache with vomiting, a falling level of consciousness, or pupil changes, because draining fluid from below can shift the brain down and herniate the brainstem. The nurse positions the patient side-lying with knees drawn up and chin tucked, or sitting and leaning over a table. Afterward the patient lies flat as ordered, and the nurse checks the site for leaking or bleeding and asks about headache and leg numbness or weakness.
An epidural goes into the same low lumbar spaces, and its most common side effect is a drop in maternal blood pressure, which reduces blood flow to the placenta and can slow the fetal heart rate. The nurse gives the ordered IV fluid bolus before placement, then checks blood pressure and fetal heart rate often per facility policy. If pressure falls, the nurse turns the patient to her side, increases IV fluids as ordered, and notifies the anesthesia provider right away.
The low back takes the most strain when a person bends and twists. The nurse protects their own back and teaches patients to bend the knees, keep the load close, and pivot the feet instead of twisting the trunk. Use a slide sheet or mechanical lift to move a patient, not the nurse's back.
Reduction of Risk PotentialPharmacological and Parenteral TherapiesBasic Care and Comfort
SpineHigh yield
Sacrum
A triangle-shaped bone made of five fused vertebrae at the base of the spine, wedged between the two hip bones to form the back wall of the pelvis.
Why the exam cares
The sacrum is the most common site for a pressure injury, because a patient lying on their back or slid down in bed rests their weight and shear right on it. It is also where signs of an incomplete spinal cord injury show up, and where a bedbound patient's fluid pools.
- Below the lumbar spine, the separate bumps give way to one broad, curved bone with a bumpy midline ridge. That bone is the sacrum.
- The two dimples on the low back sit over the posterior superior iliac spines, at about the level of the sacroiliac joints where the sacrum meets each hip bone.
- The sacrum forms the top of the cleft between the buttocks; its narrow lower tip joins the coccyx (tailbone).
- A patient lying flat or slumped in semi-Fowler's position presses the sacrum into the mattress.
The nurse inspects the sacral skin at every turn, keeps the head of the bed at 30 degrees or lower unless the patient's condition requires more so the patient does not slide and shear the skin, repositions at least every 2 hours, and keeps the skin clean and dry. Redness on intact skin that does not blanch is already a stage 1 injury. In darker skin, compare color, warmth, and firmness with the skin around it.
Fluid settles at the lowest point of the body, so in a heart-failure patient on bed rest the nurse presses over the sacrum to check for pitting, not only the ankles. New or worse sacral edema means fluid is building up and should be reported, and swollen skin here breaks down more easily.
Any feeling around the anus, or the ability to squeeze the anal sphincter on command, means some cord fibers still carry signals and the injury is incomplete. The provider tests this during the neurologic exam. The nurse records these findings, keeps up serial neuro checks, and reports any change, because it affects the outlook for recovery.
Anesthesia can be injected through the sacral hiatus, a small opening at the lower end of the sacrum, most often in children having surgery below the umbilicus. Afterward the nurse checks that movement and feeling return to the legs and watches for urinary retention, because the block also reaches the nerves that control the bladder.
Basic Care and ComfortReduction of Risk PotentialPhysiological Adaptation
SpineHigh yield
Thoracic vertebrae T1–T12
The twelve vertebrae of the mid-back, T1 through T12, where the ribs attach behind the chest and where the spine bows gently backward in the thoracic curve.
Why the exam cares
An older adult with sudden mid-back pain after a cough, a lift, or a minor fall is the exam's picture of an osteoporotic compression fracture, so the nurse checks leg strength, sensation, and bladder control and teaches fall and bone protection. These vertebrae also hold the T6 level, the injury height at or above which autonomic dysreflexia becomes a risk (see Spinal cord).
- C7 is the large bump at the base of the neck when the head bends forward; T1 is the next spinous process below it, and counting down from there finds each thoracic level.
- With the arms relaxed at the sides, the lower tip of the shoulder blade lies at about the level of T7.
- In the middle of the thoracic spine the spinous processes angle steeply downward, so the bump felt under the skin sits lower than the body of its own vertebra.
- The twelfth rib is the last rib, and it joins the spine only at T12, the bottom of the thoracic spine.
The front of a weakened vertebral body, most often in the lower thoracic or upper lumbar spine, can collapse with little force and cause sudden back pain. The nurse checks leg strength, sensation, and bowel and bladder control and reports any new deficit right away, because bone fragments can press on the cord or nerve roots. Pain is controlled so the patient can get up early, since long bed rest speeds bone loss.
Repeated small compression fractures shorten the spine and round the upper back, often without a clear injury. The nurse measures height at routine visits and reports a loss, since it can be the first sign of osteoporosis and a reason for bone density testing. Teaching covers calcium and vitamin D, weight-bearing exercise, and home fall prevention.
After a fall from a height or a car crash, the nurse keeps the head, neck, and trunk in line and turns the patient only by log-rolling with enough staff until the spine is cleared by the provider. Twisting an unstable fracture can injure the spinal cord. The nurse checks movement and sensation in the legs before and after each turn and reports any change at once.
Physiological AdaptationReduction of Risk PotentialHealth Promotion and Maintenance
Spine
Vertebral column curvatures
Seen from the side, the adult spine has four normal curves (the cervical and lumbar curves bow inward, the thoracic and sacral curves bow outward), and the three named problems are kyphosis (an exaggerated thoracic hump), lordosis (an exaggerated lumbar swayback), and scoliosis (a sideways curve).
Why the exam cares
Each abnormal curve belongs to a different patient and a different nursing action. The nurse screens teens for scoliosis and refers a positive test, watches older adults for height loss and a new hump that suggest compression fractures, and teaches the pregnant patient how to protect her back.
- From the side: the thoracic and sacral curves bow outward and are present at birth; the cervical and lumbar curves bow inward and form as the infant lifts the head and then walks.
- Kyphosis looks like a rounded hump in the upper back. Lordosis looks like a deep hollow in the low back.
- Scoliosis is seen from behind: one shoulder higher, an uneven waist crease, one hip higher, or one shoulder blade sticking out more.
- From behind, the spinous processes should run in a straight line from C7, the bump at the base of the neck, down to the sacrum.
The nurse has the child stand with feet together, then bend forward at the waist with arms hanging, and looks along the back from behind for one side of the ribs or low back sitting higher than the other. A visible rib hump or low-back bulge is a positive screen and is referred to the provider for a spine x-ray, following the school or facility screening protocol. Curves can worsen quickly during the growth spurt, so a brace is used for a moderate curve (about 25 to 40 degrees) while the child is still growing, and a severe curve (over about 45 to 50 degrees) usually needs surgery.
A new upper-back hump with lost height in an older adult suggests vertebral compression fractures from osteoporosis. The nurse measures standing height at checkups and reports a loss of about 0.8 inch (2 cm) since the last measurement, or about 1.5 inches (4 cm) from young-adult height, and asks about new back pain. The nurse teaches fall prevention, calcium and vitamin D, and weight-bearing exercise, because osteoporotic bone can break in a simple fall from standing height.
The growing uterus moves the center of gravity forward and deepens the lumbar curve, which causes low back pain and a less steady stance. The nurse teaches low-heeled shoes, pelvic tilt exercises, lifting by bending the knees, and resting on the side, and warns that the change in balance raises the risk of falling.
Health Promotion and Maintenance
