A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, and a blood pressure reading of 210/115 mm Hg. Arrange the following nursing actions in the correct priority order from first to last.
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Check the urinary catheter tubing for kinks or assess the bladder for distention.
- 3Examine the client for signs of fecal impaction.
- 4Administer the prescribed rapid-acting antihypertensive medication.
- 5Document the event, the interventions provided, and the client's response.
Answer
The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then check for bladder distention, followed by checking for bowel impaction, administering antihypertensive medication if unresolved, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension triggered by a noxious stimulus below the level of the spinal cord injury. The immediate priority is to lower the blood pressure mechanically by placing the client in a high-Fowler's position. Next, the nurse must locate and remove the triggering stimulus, starting with the most common cause (bladder distention) followed by the next most common (bowel impaction). If these non-pharmacological interventions fail, antihypertensive medications are administered. Documentation occurs last, after the client is stabilized.
Step-by-Step Solution
Key Concept
Management of Autonomic Dysreflexia