A client with a complete T4 spinal cord injury suddenly reports a severe, pounding headache and profound nasal congestion. The nurse observes profuse diaphoresis above the level of the injury and a suddenly elevated blood pressure of 218/114 mm Hg. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the final action at the bottom.)
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen any restrictive clothing or tight abdominal binders.
- 3Assess the urinary catheter for kinks or palpate the bladder for distention.
- 4Administer a prescribed rapid-acting antihypertensive medication.
- 5Document the acute episode, interventions performed, and the client's response.
Answer
The correct sequence prioritizes immediate mechanical reduction of blood pressure (elevating the head of the bed), followed by removing external triggers (loosening clothing), addressing internal triggers (checking the bladder/catheter), administering medications if needed, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled sympathetic nervous system activation below the level of the spinal cord injury, leading to life-threatening hypertension. The immediate, first-line priority is to lower the blood pressure by utilizing orthostasis (raising the head of the bed). After this initial stabilizing action, the nurse should remove external restrictive stimuli, investigate and resolve the most common internal triggers (such as a kinked catheter or distended bladder), administer antihypertensives if the noxious stimulus cannot be found or resolved, and finally document the event.
Step-by-Step Solution
Key Concept
Autonomic Dysreflexia Emergency Management
Estimated Time:1m 30s