A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The nurse observes profuse diaphoresis above the level of the spinal injury, facial flushing, and a blood pressure of 214/114 mm Hg. In what order should the nurse perform the following interventions? Arrange the actions from first to last.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen constrictive clothing, such as belts or abdominal binders.
- 3Assess the urinary catheter tubing for kinks or obstruction.
- 4Administer the prescribed PRN rapid-acting antihypertensive medication.
- 5Notify the primary healthcare provider of the event.
Answer
The correct sequence is: elevate the head of the bed, loosen constrictive clothing, assess the catheter for kinks, administer antihypertensive medication if unresolved, and then notify the healthcare provider.
In autonomic dysreflexia, a noxious stimulus below the level of injury causes an uninhibited sympathetic response, leading to severe hypertension. The sequence prioritizes immediate physiological safety (sitting the client up to drop BP), followed by trigger elimination (loosening clothes, checking the bladder), escalating to medical intervention (antihypertensives) if unresolved, and finally reporting the event.
Step-by-Step Solution
Key Concept
Autonomic Dysreflexia Emergency Management
Estimated Time:1m 30s