A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, throbbing headache and blurred vision. Assessment reveals profuse diaphoresis above the level of the injury, a heart rate of , and a blood pressure of . Arrange the following nursing interventions in the order they should be prioritized from first to last.
- 1Place the client in a high-Fowler's position
- 2Loosen constrictive clothing and restrictive bedding
- 3Assess the urinary catheter for kinks or palpate the bladder for distention
- 4Examine the rectum for a fecal impaction using an anesthetic ointment
- 5Administer a prescribed rapid-acting intravenous antihypertensive medication
Answer
The correct sequence for managing autonomic dysreflexia is: elevate the head of the bed, loosen constrictive clothing, check the bladder for distention, evaluate the bowel for impaction, and finally administer antihypertensive medications if non-pharmacological measures fail.
In autonomic dysreflexia, a massive, uncompensated cardiovascular response occurs due to stimulation of the sympathetic nervous system below the level of injury. The immediate goal is to mitigate the severe hypertension to prevent a stroke, which is achieved by sitting the client upright. Subsequently, the nurse must act rapidly to find and eliminate the cause, progressing from the most easily correctable external factors (clothing) to the most common internal factors (bladder, then bowel). Medications are reserved for refractory cases where stimulus removal is inadequate.
Step-by-Step Solution
Key Concept
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at T6 or above. It requires immediate positioning to lower blood pressure, followed by the systematic identification and removal of the triggering noxious stimulus (usually bladder or bowel).