A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and blurred vision. The client's blood pressure is 215/115 mm Hg, heart rate is 52 bpm, and they have profound diaphoresis above the level of the injury. In what order should the nurse perform the following interventions? Arrange the actions from highest priority (first) to lowest priority (last).
- 1Place the client in a high Fowler's position.
- 2Loosen any constrictive clothing or tight devices.
- 3Assess the bladder for distention and check the urinary catheter for kinks.
- 4Administer the prescribed short-acting antihypertensive medication.
Answer
The correct sequence is: Place the client in a high Fowler's position, loosen any constrictive clothing, assess the bladder for distention, and finally administer the prescribed short-acting antihypertensive medication.
Autonomic dysreflexia is a neurologic emergency that occurs in clients with a spinal cord injury at or above the T6 level. It is caused by a noxious stimulus below the level of injury, leading to an uninhibited sympathetic response. The priority is to decrease the blood pressure immediately to prevent a stroke by elevating the head of the bed to a high Fowler's position. The next step is to remove any rapid external stimuli by loosening constrictive clothing. Then, the nurse must systematically assess for internal triggers, with bladder distention being the most common. Finally, if conservative measures and removal of the stimulus fail to reduce the blood pressure, the nurse should administer a prescribed short-acting antihypertensive medication.
Step-by-Step Solution
Key Concept
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6, requiring immediate positioning to lower blood pressure, followed by identification and removal of triggering stimuli.