A registered nurse is caring for a client with a T4 spinal cord injury who suddenly develops a pounding headache, blurred vision, and a flushed face. Assessment reveals profuse diaphoresis above the level of the injury, bradycardia at 52 beats/minute, and a blood pressure of 210/114 mm Hg. Arrange the following nursing interventions in the prioritized order of execution from first to last.
- 1Elevate the head of the bed to a high Fowler's position
- 2Loosen any constrictive clothing or restrictive devices
- 3Assess the urinary catheter tubing for kinks or obstruction
- 4Evaluate the rectum for fecal impaction using an anesthetic ointment
- 5Administer the prescribed short-acting antihypertensive medication
Answer
The correct priority sequence is: 1) Elevate the head of the bed, 2) Loosen constrictive clothing, 3) Assess the urinary catheter, 4) Evaluate the rectum for impaction, and 5) Administer the prescribed antihypertensive medication.
The established priority sequence for autonomic dysreflexia focuses first on mitigating the immediate risk of stroke via orthostatic hypotension (sitting up), followed by rapidly removing external triggers (clothing), assessing the most common internal triggers sequentially (bladder, then bowel), and finally using medications if conservative measures fail.
Step-by-Step Solution
Key Concept
In autonomic dysreflexia, prioritization dictates immediately lowering the blood pressure through positional changes (High Fowler's), followed by a systematic search for and elimination of the noxious stimuli (clothing, bladder, bowel), reserving pharmacological therapy for unresolved hypertension.