A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and becomes profusely diaphoretic above the level of injury. The client's blood pressure is 210/110 mmHg and heart rate is 52 bpm. In what order should the nurse perform the following actions? Arrange the actions in chronological sequence from first to last.
- 1Elevate the head of the bed to 90 degrees.
- 2Assess for and relieve the underlying noxious stimulus, such as a kinked urinary catheter.
- 3Administer the prescribed short-acting antihypertensive medication.
- 4Document the occurrence, interventions, and the client's response.
Answer
The correct sequence is: elevate the head of the bed to 90 degrees, assess for and relieve the underlying noxious stimulus, administer the prescribed short-acting antihypertensive medication, and document the occurrence, interventions, and the client's response.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension and bradycardia in clients with spinal cord injuries at or above the T6 level. The immediate priority is to lower the blood pressure by placing the client in a high Fowler's position (90 degrees) to induce orthostasis. Next, the nurse must identify and remove the noxious stimulus, such as bladder distention or a kinked catheter, which is the underlying cause of the sympathetic surge. If these conservative measures do not resolve the severe hypertension, a prescribed short-acting antihypertensive medication is administered. Finally, the nurse documents the event once the client's condition is stable.
Step-by-Step Solution
Key Concept
Management of autonomic dysreflexia involves immediate positional changes to lower blood pressure, followed by identification and removal of the triggering stimulus.