A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mmHg, and a heart rate of 48 beats/min. Arrange the following nursing actions in the correct priority sequence. (Place the most immediate priority action at the top.)
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen the client's restrictive clothing and abdominal binder.
- 3Palpate the bladder and check the urinary catheter for kinks.
- 4Administer the prescribed PRN rapidly acting antihypertensive.
- 5Notify the healthcare provider of the acute episode.
Answer
The correct sequence of actions for a client experiencing autonomic dysreflexia is: elevate the head of the bed, loosen restrictive clothing, assess for the trigger (bladder/bowel), administer antihypertensive medications if needed, and notify the healthcare provider.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension and bradycardia due to an exaggerated sympathetic response, usually triggered by a lower body stimulus in clients with spinal cord injuries at or above T6. The absolute first priority is to place the client in a sitting or high Fowler's position to utilize orthostatic hypotension to lower the blood pressure. Next, immediate external triggers (like tight clothing) are removed. The nurse then assesses for the most common internal triggers, such as bladder distention or a kinked catheter. If these conservative measures do not resolve the hypertensive crisis, antihypertensive medications are administered. Finally, the provider is notified.
Step-by-Step Solution
Key Concept
Management of autonomic dysreflexia requires immediate intervention to lower blood pressure, primarily through positioning, followed by rapid identification and removal of the triggering stimulus.