A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. Upon assessment, the nurse notes profuse diaphoresis on the client's face and neck, severe facial flushing, a blood pressure of 218/114 mm Hg, and a heart rate of 52 beats/min. The client has an indwelling urinary catheter in place. Arrange the following nursing interventions in the correct order of priority, from first to last.
- 1Elevate the head of the bed to a high Fowler's (90-degree) position.
- 2Loosen any tight clothing, belts, or restrictive abdominal binders.
- 3Assess the indwelling urinary catheter tubing for kinks and ensure unobstructed flow.
- 4Administer a prescribed rapid-acting antihypertensive medication if symptoms persist.
- 5Document the clinical event, interventions performed, and the client's physiological response.
Answer
The correct sequence of actions for managing autonomic dysreflexia is: elevate the head of the bed, loosen restrictive clothing, assess the urinary catheter for kinks, administer a prescribed antihypertensive medication if symptoms persist, and finally document the event.
In autonomic dysreflexia, a massive uncompensated cardiovascular reaction occurs mediated by the sympathetic nervous system. The immediate priority is to lower the blood pressure to prevent a stroke, which is achieved first by utilizing gravity (elevating the head of the bed). Following this immediate safety measure, the nurse systematically removes potential triggers, starting with quick external checks (loosening clothing) and then checking the most common internal cause (bladder distention). Medical intervention with antihypertensives follows if these steps fail, and administrative tasks like documentation always come last.
Step-by-Step Solution
Key Concept
Management of Autonomic Dysreflexia (Hyperreflexia)