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 blurred vision. The nurse notes profuse diaphoresis and flushing above the level of the injury. The client's blood pressure is 210/115 mm Hg, and the heart rate is 52 beats/min. Arrange the following nursing actions in the correct priority order.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen constrictive clothing and assess the urinary catheter for kinks.
- 3Assess the client's rectum for a fecal impaction if the bladder is empty.
- 4Administer a prescribed rapid-acting antihypertensive medication.
- 5Document the clinical event, the interventions implemented, and the client's response.
Answer
The correct priority sequence is to first elevate the head of the bed, then loosen clothing and check the bladder, assess for a fecal impaction, administer an antihypertensive medication if needed, and finally document the event.
In autonomic dysreflexia, the priority is preventing a stroke from severe hypertension. Elevating the head of the bed provides immediate orthostatic relief. The nurse then systematically assesses for and removes noxious stimuli below the level of the injury, starting with the bladder (most common) and then the bowel. Medications are a secondary intervention if trigger removal fails. Documentation is the final step after stabilization.
Step-by-Step Solution
Key Concept
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6. Management prioritizes immediately lowering blood pressure through positioning (high Fowler's), followed by identifying and removing the triggering noxious stimulus (most commonly a full bladder or bowel).