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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and nasal congestion. The PN observes profuse sweating above the level of the spinal injury. Arrange the following nursing actions in the priority order the PN should perform them.

  1. 1Elevate the head of the bed to a sitting or high-Fowler's position.
  2. 2Measure the client's blood pressure.
  3. 3Inspect the urinary catheter tubing for kinks or blockages.
  4. 4Notify the registered nurse (RN) of the client's status.

Answer

The correct priority sequence is to first elevate the head of the bed, followed by measuring the blood pressure, inspecting the urinary catheter, and finally notifying the registered nurse.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension. The absolute first action must be to elevate the head of the bed, which takes seconds and uses gravity to lower blood pressure, preventing a stroke. Next, the PN must obtain a blood pressure reading to confirm the crisis. Once confirmed, the PN should look for the most common cause, which is a distended bladder, by checking the catheter. Finally, the RN is notified to report the event, current vital signs, and seek potential pharmacological interventions.

Step-by-Step Solution

1
Elevate the head of the bed to a sitting or high-Fowler's position.
The client is positioned upright.
Gravity immediately causes orthostatic hypotension, which helps safely lower the dangerously high blood pressure and reduces the immediate risk of a cerebrovascular accident (stroke).
2
Measure the client's blood pressure.
Objective vital sign data is obtained.
Checking the blood pressure confirms the severity of the suspected autonomic dysreflexia and provides a baseline to determine if subsequent interventions are effective.
3
Inspect the urinary catheter tubing for kinks or blockages.
A potential noxious stimulus (bladder distention) is investigated and resolved if found.
Autonomic dysreflexia is triggered by an uninhibited sympathetic response to a noxious stimulus below the level of the injury. A blocked catheter is the most frequent culprit and can be fixed immediately at the bedside.
4
Notify the registered nurse (RN) of the client's status.
The healthcare team is alerted to the medical emergency.
The RN needs the vital signs and assessment findings to coordinate further care, which may include administering emergency antihypertensive medications if relieving the physical stimulus is ineffective.

Key Concept

Prioritization of emergency nursing actions for a client experiencing autonomic dysreflexia.
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Topics

Physiological Adaptation

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