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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client with a T4 spinal cord injury who suddenly complains of a severe, throbbing headache. The nurse notes profuse diaphoresis above the level of the injury, flushing of the skin, and a blood pressure of 210/115 mmHg. Arrange the following nursing interventions in the correct order of priority from first to last.

  1. 1Elevate the head of the bed to a high Fowler's position.
  2. 2Loosen any constrictive clothing or tight devices.
  3. 3Assess the bladder for distention and check the urinary catheter for kinks.
  4. 4Administer a prescribed short-acting antihypertensive medication.
  5. 5Document the clinical findings, interventions provided, and the client's response.

Answer

First, elevate the head of the bed. Second, loosen constrictive clothing. Third, assess the bladder for distention or catheter kinks. Fourth, administer a short-acting antihypertensive if symptoms persist. Finally, document the event and the client's response.
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6. The correct prioritization focuses on immediately mitigating the most dangerous symptom (hypertension) followed by identifying and removing the trigger. Elevating the head of the bed lowers blood pressure via orthostasis. Loosening tight clothing and assessing the bladder (the most common cause) are the next steps to eliminate the noxious stimuli. If these measures fail, antihypertensives are necessary. Documentation is the final step after stabilization.

Step-by-Step Solution

1
Recognize the signs of autonomic dysreflexia in a client with a spinal cord injury at or above T6.
The nurse identifies the throbbing headache, diaphoresis, flushing, and severe hypertension as a medical emergency requiring immediate intervention.
Early recognition prevents life-threatening complications such as a stroke.
2
Prioritize interventions based on the immediate threat to life.
Elevating the head of the bed is chosen as the first action.
Sitting the client upright immediately takes advantage of orthostatic hypotension to lower the dangerous blood pressure, addressing the most critical threat.
3
Determine the sequence for eliminating potential triggers.
Loosening tight clothing is done quickly, followed immediately by assessing the most common internal trigger (bladder).
Removing external noxious stimuli is fast and non-invasive, while bladder assessment addresses the most statistically probable internal cause.
4
Determine the role of medication and documentation in the sequence.
Medication is given if non-pharmacological removal of stimuli fails, and documentation is performed last.
Antihypertensives are a secondary line of treatment if the underlying cause cannot be rapidly fixed. Documentation always follows stabilization.

Key Concept

Prioritization of care for Autonomic Dysreflexia
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Topics

Physiological Adaptation

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