A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache, and the nurse notes profound facial flushing and diaphoresis above the level of the injury. The client's current blood pressure is 218/114 mm Hg. Arrange the following nursing interventions in the priority order they should be performed, from first to last.
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Loosen any constrictive clothing or tight devices on the client.
- 3Assess the urinary catheter for kinks or palpate for bladder distention.
- 4Administer a prescribed rapid-acting intravenous antihypertensive medication.
- 5Document the clinical event, interventions performed, and client response.
Answer
The priority sequence is to first elevate the head of the bed, followed by loosening constrictive clothing, assessing for the noxious stimulus, administering antihypertensives if the condition persists, and finally documenting the event.
In autonomic dysreflexia, the immediate goal is to lower the blood pressure to prevent a stroke while simultaneously hunting for the trigger. Elevating the head of the bed achieves the fastest drop in blood pressure. Once positioned safely, the nurse systematically removes triggers from least invasive (clothing) to most common (bladder/bowel). Medications are reserved for when removing triggers fails to resolve the severe hypertension.
Step-by-Step Solution
Key Concept
Management of autonomic dysreflexia in spinal cord injuries