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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client with a T3 spinal cord injury who suddenly reports a severe, throbbing headache. The client presents with facial erythema, diaphoresis above the level of the lesion, and a blood pressure of 215/115 mmHg. Arrange the following nursing actions in the correct priority sequence from first to last.

  1. 1Position the client in a high-Fowler's position.
  2. 2Loosen any restrictive clothing or tight devices.
  3. 3Assess the indwelling urinary catheter tubing for kinks or obstruction.
  4. 4Administer the prescribed PRN rapid-acting antihypertensive medication.

Answer

The correct priority sequence is: Position the client in a high-Fowler's position, then loosen restrictive clothing, followed by assessing the urinary catheter, and finally administering the antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension in clients with spinal cord injuries at or above T6. The initial action is always to elevate the head of the bed to 90 degrees (high-Fowler's) to immediately decrease blood pressure through orthostasis. Next, constrictive clothing should be loosened to remove surface stimuli. The nurse then systematically assesses for and eliminates the noxious stimulus, starting with the most common cause: bladder distension or catheter obstruction. Finally, if conservative measures fail to lower the blood pressure, prescribed antihypertensives are administered.

Step-by-Step Solution

1
Position the client in a high-Fowler's position.
The client is sitting upright, utilizing gravity to induce orthostatic hypotension.
Extreme hypertension places the client at immediate risk for a cerebral hemorrhage. Sitting the client up is the fastest way to lower blood pressure before gathering equipment or conducting further assessments.
2
Loosen any restrictive clothing or tight devices.
Potential cutaneous triggers, such as a tight belt or restrictive blanket, are removed.
Cutaneous stimulation can trigger or exacerbate the sympathetic nervous system response. This is a rapid intervention performed immediately after positioning.
3
Assess the indwelling urinary catheter tubing for kinks or obstruction.
The nurse checks for the most common cause of autonomic dysreflexia.
A distended bladder is the leading cause of this condition. Identifying and eliminating the noxious stimulus is the primary definitive treatment to stop the sympathetic surge.
4
Administer the prescribed PRN rapid-acting antihypertensive medication.
Pharmacological management is initiated to control blood pressure.
If removing the noxious stimuli (such as clothing or bladder distension) does not quickly resolve the crisis, or if the cause cannot be immediately found, antihypertensive medications are required to protect the client.

Key Concept

Autonomic Dysreflexia Prioritization
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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