While conducting hourly rounds, a nurse evaluates a client who sustained a T4 spinal cord injury three weeks ago. The client suddenly reports a severe, throbbing headache and blurred vision. The nurse notes profuse diaphoresis above the level of the injury and a blood pressure of 215/115 mm Hg. Arrange the following clinical interventions in the prioritized sequence they should be performed.
- 1Elevate the head of the bed to a sitting or high-Fowler's position.
- 2Assess the urinary catheter for kinks and palpate the bladder for distention.
- 3Administer the prescribed rapid-acting PRN antihypertensive medication.
- 4Document the clinical presentation, interventions performed, and client response.
Answer
The correct sequence of actions for managing autonomic dysreflexia is to first place the client in an upright position, then identify and relieve the triggering stimulus, followed by administering prescribed antihypertensives if the blood pressure remains elevated, and finally documenting the event.
In the setting of autonomic dysreflexia, the immediate life-threatening risk is a cerebrovascular accident due to severe hypertension. Raising the head of the bed is the fastest, non-invasive way to lower blood pressure via orthostasis. The next step is to find and eliminate the underlying cause (usually bladder distention). Medications follow if symptoms persist, and documentation concludes the triage process.
Step-by-Step Solution
Key Concept
Prioritization of Interventions for Autonomic Dysreflexia