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Difficulty: MediumPhysiological Adaptation

A client with a complete transection spinal cord injury at the T4 level suddenly reports a severe, pounding headache and blurred vision. Upon evaluation, profuse diaphoresis is noted above the level of the injury alongside a blood pressure reading of 215/115 mm Hg. Arrange the following nursing actions in the priority order they should be performed, from first to last.

  1. 1Elevate the head of the bed to a high Fowler's position.
  2. 2Loosen any restrictive clothing or tight devices.
  3. 3Assess the urinary drainage system for kinks or bladder distention.
  4. 4Examine the rectum for the presence of a fecal impaction.
  5. 5Administer a rapidly acting intravenous antihypertensive medication.

Answer

The correct sequence is to first elevate the head of the bed, loosen restrictive clothing, assess the bladder, examine the bowel, and finally administer antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension in clients with spinal cord injuries at or above T6. The priority sequence follows a strict 'immediate safety first, then treat the cause' approach: rapidly lowering blood pressure via orthostasis (sitting up) is always the immediate first action. This is followed by systematically identifying and removing the offending noxious stimuli, starting from the most external and common (tight clothing, full bladder) to the next most common (bowel impaction). Pharmacological intervention is the final step if mechanical removal of stimuli fails.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Takes advantage of orthostatic hypotension to lower blood pressure.
The client is experiencing a hypertensive emergency due to autonomic dysreflexia. The most immediate mechanical way to lower blood pressure and prevent stroke is to utilize gravity.
2
Loosen any restrictive clothing or tight devices.
Reduces external skin stimulation.
Tight clothing, tight sheets, or restrictive devices act as noxious sensory stimuli below the level of injury, driving the exaggerated sympathetic response.
3
Assess the urinary drainage system for kinks or bladder distention.
Identifies or rules out the primary cause of autonomic dysreflexia.
A distended bladder is the single most common cause of autonomic dysreflexia. Emptying the bladder often abruptly stops the crisis.
4
Examine the rectum for the presence of a fecal impaction.
Identifies or rules out the secondary cause of autonomic dysreflexia.
If the bladder is not the source, the bowel is the next most likely culprit. This must be checked to remove the noxious stimulus.
5
Administer a rapidly acting intravenous antihypertensive medication.
Pharmacologically lowers the blood pressure.
Medications are used only when conservative measures fail to eliminate the noxious stimuli or if the blood pressure remains critically elevated despite removing the trigger.

Key Concept

Prioritization and Management of Autonomic Dysreflexia
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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