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Difficulty: MediumPhysiological Adaptation

During morning rounds, a client with a history of a T4 spinal cord injury suddenly reports a severe, pounding headache. The practical nurse observes that the client is experiencing profuse sweating above the level of the chest and exhibits nasal congestion. Which immediate interventions are appropriate for this client? Select all that apply.

  1. Raise the head of the bed to a high Fowler's position.Answer
  2. Obtain the client's blood pressure reading immediately.Answer
  3. Check the urinary catheter and drainage tubing for any obstructions.Answer
  4. D
    Provide a prescribed oral analgesic to relieve the severe headache.
  5. E
    Administer a prescribed intravenous (IV) push antihypertensive medication.

Answer

The correct immediate actions are to raise the head of the bed, obtain a blood pressure reading, and check the urinary catheter for obstructions.
The client is exhibiting classic signs of autonomic dysreflexia, a severe hypertensive crisis triggered by a noxious stimulus below the level of the spinal cord injury (T4). Elevating the head of the bed immediately helps lower blood pressure through orthostasis. Obtaining a blood pressure reading confirms the hypertensive crisis and establishes a baseline, while checking the urinary system addresses the most common cause of the syndrome (bladder distention from a kinked or blocked catheter).

Step-by-Step Solution

1
Identify the clinical presentation.
The client's symptoms (pounding headache, profuse diaphoresis above the injury level, nasal congestion) in the context of a T4 spinal cord injury indicate autonomic dysreflexia.
Recognizing the syndrome is the critical first step in clinical judgment for a sudden client status change.
2
Prioritize immediate circulation and safety interventions.
Raising the head of the bed utilizes orthostatic pressure to help lower the blood pressure quickly.
This is a rapid, non-pharmacological way to mitigate the extreme hypertensive crisis.
3
Collect objective data and attempt to identify the trigger.
The nurse checks the blood pressure to confirm the severity of hypertension and inspects the urinary catheter.
Bladder distention is the most frequent noxious stimulus causing this reflex; removing the trigger is essential to resolving autonomic dysreflexia.

Key Concept

Autonomic dysreflexia is a medical emergency characterized by sudden, extreme hypertension in clients with spinal cord injuries above T6, requiring immediate positioning, data collection, and removal of the triggering stimulus.
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Topics

Physiological Adaptation

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