A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. Assessment reveals a blood pressure of 210/115 mm Hg, a heart rate of 54 beats/minute, and profuse diaphoresis above the level of the spinal lesion. Arrange the following nursing actions in the correct order of priority.
- 1Place the client in a high-Fowler's position.
- 2Loosen any restrictive clothing or tight devices.
- 3Check the urinary catheter tubing for kinks or blockage.
- 4Administer a prescribed rapid-acting antihypertensive medication.
Answer
The correct priority sequence is to first elevate the head of the bed, then loosen restrictive clothing, followed by checking the urinary catheter for blockages, and finally administering an antihypertensive medication if symptoms persist.
In the event of autonomic dysreflexia, the primary goal is to prevent a cerebrovascular accident by rapidly lowering the blood pressure while simultaneously identifying and removing the trigger. Elevating the head of the bed is the fastest mechanical way to lower blood pressure. Loosening tight clothing removes immediate surface triggers. Checking the catheter addresses the most common internal trigger (bladder distention). If these steps fail, pharmacological intervention is the final priority.
Step-by-Step Solution
Key Concept
Prioritization in Autonomic Dysreflexia Management