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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache. Assessment reveals profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mm Hg, and a heart rate of 54 bpm. Arrange the following nursing interventions in the correct priority sequence, from first to last.

  1. 1Place the client in a high Fowler's position.
  2. 2Assess the indwelling urinary catheter tubing for kinks or obstruction.
  3. 3Examine the rectum for fecal impaction using an anesthetic ointment.
  4. 4Administer the prescribed PRN rapid-acting antihypertensive medication.

Answer

The correct sequence is: Place the client in a high Fowler's position, assess the urinary catheter for kinks, examine the rectum for impaction, and finally administer the prescribed antihypertensive medication.
The correct sequence prioritizes immediate physiological safety by inducing orthostatic hypotension through upright positioning, followed by a systematic assessment to eliminate the most common noxious stimuli (bladder then bowel), and finally utilizing pharmacological intervention if the stimulus cannot be resolved.

Step-by-Step Solution

1
Recognize the clinical presentation of autonomic dysreflexia.
The client has a T4 spinal cord injury, severe hypertension, bradycardia, headache, and diaphoresis.
Identifying the medical emergency is required to initiate the correct crisis management protocol.
2
Determine the priority first action to mitigate immediate risk.
Positioning the client upright in a high Fowler's position is the immediate first step.
Raising the head of the bed induces orthostatic hypotension, which rapidly decreases the blood pressure and minimizes the risk of a stroke.
3
Sequence the assessment for triggering noxious stimuli.
Checking the bladder and catheter comes before checking the bowel.
Bladder distention is the most frequent cause of autonomic dysreflexia, making it the highest priority assessment after positioning. Bowel impaction is the second most common.
4
Determine the role of pharmacological intervention.
Administering antihypertensive medication is the final step in this sequence.
Medications are indicated only if the blood pressure remains elevated after the noxious stimuli have been identified and removed, or if the stimulus cannot be immediately resolved.

Key Concept

Autonomic dysreflexia is a life-threatening emergency in clients with spinal cord injuries at or above T6, requiring immediate upright positioning followed by the identification and removal of noxious stimuli (usually bladder or bowel).
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Topics

Physiological Adaptation

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