A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN observes profuse diaphoresis and flushing above the level of the injury. Arrange the following actions in the order the PN should perform them, from first to last.
- 1Elevate the head of the bed to a sitting or high-Fowler's position.
- 2Measure the client's blood pressure to confirm hypertension.
- 3Assess the client's indwelling urinary catheter for kinks or blockages.
- 4Notify the registered nurse (RN) or healthcare provider of the client's condition.
Answer
The correct sequence of actions is: 1) Elevate the head of the bed to a sitting or high-Fowler's position; 2) Measure the client's blood pressure to confirm hypertension; 3) Assess the client's indwelling urinary catheter for kinks or blockages; 4) Notify the registered nurse (RN) or healthcare provider of the client's condition.
The client is exhibiting classic signs of autonomic dysreflexia, a medical emergency in clients with spinal cord injuries above T6. The immediate priority is to lower the blood pressure by utilizing orthostatic changes (elevating the head of the bed). Once repositioned, the blood pressure must be measured to confirm the hypertensive crisis. Next, the PN should assess for and remove the most common triggering stimulus, which is typically bladder distention from a blocked catheter. Finally, the RN must be notified to collaborate on further management and potential pharmacological interventions.
Step-by-Step Solution
Key Concept
Prioritization in Acute Neurological Emergencies (Autonomic Dysreflexia)