A nurse is caring for a client who sustained a spinal cord injury at the T4 level one month ago. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of injury, and the blood pressure is . Arrange the following nursing actions in the priority order they should be performed.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Assess the urinary catheter for kinks and the bladder for distension.
- 3Assess for bowel impaction if the urinary system is draining appropriately.
- 4Administer the prescribed PRN rapid-acting antihypertensive medication.
- 5Document the precipitating trigger, nursing interventions, and the client's physiological response.
Answer
The correct sequence prioritizes immediate physiological safety by altering hemodynamics, followed by systematically identifying and removing the physical triggers, utilizing pharmacological therapy if conservative measures fail, and concluding with documentation.
In autonomic dysreflexia, a massive sympathetic response occurs due to a noxious stimulus below the level of the spinal cord injury. The absolute priority is to immediately lower the blood pressure to prevent a stroke, which is achieved first by elevating the head of the bed. Next, the nurse must systematically identify and eliminate the stimulus. Bladder issues are the most common cause, followed by bowel impaction. If removing these physical triggers does not resolve the crisis, antihypertensive medications are administered. Documentation is completed last.
Step-by-Step Solution
Key Concept
Management of Autonomic Dysreflexia