A practical nurse (PN) enters the room of a client who has a T4 spinal cord injury. The client reports a sudden, severe pounding headache and blurred vision. The PN observes profuse diaphoresis above the level of the spinal injury and measures 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)
- 1Elevate the head of the bed to a 90-degree angle.
- 2Inspect the client's indwelling urinary catheter tubing for kinks or blockages.
- 3Notify the supervising registered nurse (RN) of the acute status change.
- 4Administer the prescribed PRN fast-acting oral antihypertensive medication.
- 5Document the vital signs, interventions, and the client's response.
Answer
The correct order of actions is to first elevate the head of the bed, followed by inspecting the urinary catheter for blockages, notifying the supervising RN, administering prescribed antihypertensive medication, and finally documenting the event.
Autonomic dysreflexia is a life-threatening hypertensive emergency that occurs in clients with spinal cord injuries at or above the T6 level. The prioritization of care must focus on immediate physiological stabilization. The absolute first action is to elevate the head of the bed to a high-Fowler's position; this immediately helps lower the blood pressure through orthostasis and reduces the risk of cerebral hemorrhage. Next, the nurse must assess for and remove the most common triggering stimulus, which is bladder distention, by checking the catheter for kinks or blockages. If the stimulus cannot be resolved or blood pressure remains high, the nurse must immediately notify the RN to escalate care, followed by administering prescribed PRN antihypertensive medications as directed. Finally, once the crisis is managed and the client is stable, the nurse documents the event, the interventions performed, and the client's response.
Step-by-Step Solution
Key Concept
Autonomic Dysreflexia Emergency Management