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Difficulty: HardPhysiological Adaptation

A nurse in the neurological intensive care unit is evaluating a client who sustained a complete T3 spinal cord injury two months ago. The client suddenly reports a severe, throbbing headache and blurred vision. The nurse observes pronounced flushing and diaphoresis on the client's face, neck, and upper chest, while the skin on the lower extremities is pale and cool. Vital signs reveal a blood pressure of 210/110 mmHg, a heart rate of 48 beats/min, and respirations of 22 breaths/min. Which immediate nursing actions are appropriate? Select all that apply.

  1. Elevate the head of the bed to a high Fowler's position.Answer
  2. B
    Position the client supine with the lower extremities elevated.
  3. Assess the patency of the indwelling urinary catheter or palpate the bladder.Answer
  4. D
    Administer a rapid intravenous fluid bolus of 0.9% sodium chloride.
  5. Loosen any constrictive clothing, tight compression stockings, or restrictive bedding.Answer
  6. F
    Delegate to the unlicensed assistive personnel (UAP) to continuously monitor vital signs.

Answer

The correct immediate actions are elevating the head of the bed to a high Fowler's position, assessing the patency of the urinary catheter, and loosening any constrictive clothing.
The client is experiencing autonomic dysreflexia, a life-threatening hypertensive emergency occurring in clients with spinal cord injuries at or above the T6 level. Immediate management focuses on lowering blood pressure and removing the noxious stimulus. Elevating the head of the bed to a high Fowler's position utilizes orthostasis to rapidly lower blood pressure. Because bladder distention is the most common trigger, assessing catheter patency or checking for urinary retention is a critical next step. Loosening constrictive clothing removes another common peripheral sensory trigger.

Step-by-Step Solution

1
Analyze the client's clinical presentation and history.
The client has a T3 spinal cord injury and presents with severe hypertension, bradycardia, headache, and diaphoresis above the injury level.
These are the classic hallmark signs of autonomic dysreflexia, a medical emergency triggered by a noxious stimulus below the level of the injury (typically T6 or higher).
2
Determine the priority physiological intervention to prevent immediate harm.
The priority is to immediately reduce the dangerously high blood pressure by utilizing orthostasis (elevating the head of the bed).
Severe hypertension in autonomic dysreflexia can quickly lead to a stroke or myocardial infarction if not managed instantly.
3
Identify interventions aimed at removing the underlying cause.
Assess the urinary system for distention or catheter blockages, check the bowel for impaction, and remove any tight clothing.
The hypertensive crisis will not resolve until the triggering noxious stimulus is identified and eliminated.

Key Concept

Management of Autonomic Dysreflexia in Spinal Cord Injury
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Topics

Physiological Adaptation

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