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Difficulty: HardPhysiological Adaptation

A practical nurse (PN) is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The PN observes profuse diaphoresis above the level of the injury and records a blood pressure of 210/110 mm Hg. In which order should the PN perform the following actions? Arrange the actions from first to last.

  1. 1Elevate the head of the bed to a high-Fowler's position.
  2. 2Examine the indwelling urinary catheter system for kinks or obstructions.
  3. 3Contact the registered nurse (RN) to report the abnormal findings.
  4. 4Document the client's vital signs and the sequence of events.

Answer

The correct sequence is: 1) Elevate the head of the bed, 2) Examine the urinary catheter, 3) Contact the registered nurse (RN), and 4) Document the findings.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension and a pounding headache in clients with spinal cord injuries above T6. The first action is always to elevate the head of the bed to use orthostatic pressure changes to lower the blood pressure. Next, the PN must search for and resolve the trigger, which is most often a distended bladder caused by a kinked catheter. After taking these immediate independent bedside actions, the PN must notify the RN. Finally, the event and interventions should be documented once the client is safe.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's position.
The client's upper body is raised, promoting orthostatic changes.
This immediately helps to lower the dangerously high blood pressure and decreases the risk of cerebral hemorrhage before any other action is taken.
2
Examine the indwelling urinary catheter system for kinks or obstructions.
The source of the autonomic dysreflexia trigger is identified and potentially resolved.
Bladder distention is the most common noxious stimulus causing autonomic dysreflexia; removing the stimulus halts the sympathetic nervous system surge.
3
Contact the registered nurse (RN) to report the abnormal findings.
The supervising nurse is informed of the acute change in status.
The RN or healthcare provider must be notified to evaluate the client, adjust the plan of care, or administer prescribed antihypertensive medications if the blood pressure does not resolve.
4
Document the client's vital signs and the sequence of events.
A legal and clinical record of the emergency and interventions is created.
Documentation is completed after the client is stabilized and the healthcare team is notified.

Key Concept

Prioritization of care for a client experiencing autonomic dysreflexia
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Topics

Physiological Adaptation

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