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Difficulty: Very hardPhysiological Adaptation

A practical nurse (PN) is collecting data on a client who has a complete spinal cord injury at the T4 level. The client suddenly reports a severe, throbbing headache and blurred vision. The PN observes profound diaphoresis on the client's face and neck, and the blood pressure is 215/115 mm Hg. Arrange the following nursing actions in the priority order the PN should perform them. (Place the first action at the top and the last action at the bottom.)

  1. 1Elevate the head of the bed to a high Fowler's position.
  2. 2Loosen any constrictive clothing, abdominal binders, or anti-embolism stockings.
  3. 3Inspect the indwelling urinary catheter tubing for kinks, obstruction, or dependent loops.
  4. 4Reassess the client's blood pressure and heart rate.
  5. 5Notify the registered nurse (RN) and health care provider (HCP) of the client's condition.

Answer

The correct priority order is: 1) Elevate the head of the bed to a high Fowler's position, 2) Loosen any constrictive clothing or restrictive devices, 3) Inspect the indwelling urinary catheter tubing for kinks, 4) Reassess the client's blood pressure and heart rate, and 5) Notify the registered nurse (RN) and health care provider (HCP).
Autonomic dysreflexia is a life-threatening neurologic emergency characterized by a massive sympathetic surge in clients with spinal cord injuries at or above T6. The immediate priority is to lower the blood pressure to prevent a hemorrhagic stroke. Elevating the head of the bed accomplishes this rapidly through orthostatic hypotension. Once the client is upright, the nurse sequentially addresses external and internal noxious stimuli by loosening clothing and checking for bladder distention (the most frequent trigger). After removing potential triggers, the nurse reassesses the vital signs to evaluate the effectiveness of the interventions. Finally, the RN and HCP must be notified, especially if pharmacological management is required for persistent hypertension.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
The client is placed in an upright, seated position.
This immediately induces orthostatic hypotension, using gravity to rapidly decrease the dangerously high blood pressure and prevent a stroke.
2
Loosen any constrictive clothing, abdominal binders, or anti-embolism stockings.
External restrictions and pressure points are removed.
Removing external physical irritants eliminates superficial noxious stimuli that can trigger or sustain the massive sympathetic response.
3
Inspect the indwelling urinary catheter tubing for kinks, obstruction, or dependent loops.
The urinary drainage system is assessed and restored to patency if blocked.
Bladder distention is the most common internal trigger for autonomic dysreflexia; resolving the blockage eliminates the primary noxious stimulus.
4
Reassess the client's blood pressure and heart rate.
Vital signs are evaluated following initial interventions.
Reassessment determines if the independent nursing interventions successfully lowered the blood pressure and resolved the sympathetic surge.
5
Notify the registered nurse (RN) and health care provider (HCP) of the client's condition.
The healthcare team is alerted to the client's status.
If conservative measures fail to resolve the hypertensive crisis, medical intervention (such as administering rapid-acting antihypertensive medications) is urgently required.

Key Concept

Prioritization of care for a client experiencing autonomic dysreflexia, focusing on immediate mechanical reduction of blood pressure followed by the sequential removal of external and internal noxious stimuli.
Estimated Time:2m 0s
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Topics

Physiological Adaptation

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