A client with a spinal cord injury at the T4 level reports a sudden, severe pounding headache and blurred vision. The practical nurse (PN) notes the client is profusely sweating and has a flushed face. The client's blood pressure is 208/112 mm Hg. In what order should the PN perform the following actions? Arrange the actions from first to last.
- 1Elevate the head of the bed to a high Fowler's (sitting) position.
- 2Check the client's urinary catheter tubing for kinks or obstruction.
- 3Notify the registered nurse (RN) of the client's acute symptoms.
- 4Monitor the client's blood pressure every 10 to 15 minutes.
Answer
The correct sequence is to first elevate the head of the bed, then check the urinary catheter for kinks, notify the registered nurse, and finally monitor the blood pressure frequently.
In the event of autonomic dysreflexia, the primary life-threatening risk is a severe hypertensive crisis that can lead to a stroke. The very first action must always be to elevate the head of the bed to a sitting (high Fowler's) position, as this uses gravity to immediately lower the blood pressure (orthostatic hypotension). Once the client is safely positioned, the practical nurse must quickly assess for and remove the noxious stimulus, which is most commonly a distended bladder caused by a kinked catheter. After these immediate independent bedside interventions are completed, the nurse must notify the registered nurse to coordinate potential pharmacological treatment. Finally, the nurse continues to monitor the blood pressure every 10 to 15 minutes to evaluate the effectiveness of the interventions.
Step-by-Step Solution
Key Concept
Prioritization of care for autonomic dysreflexia involves immediate blood pressure reduction through positioning, followed by elimination of the triggering stimulus.