A nurse is caring for a client who sustained a complete spinal cord injury at the T4 level three weeks ago. The client suddenly reports a severe, throbbing headache, blurred vision, and nasal congestion. The nurse observes profuse diaphoresis on the client's face and neck, with distinct piloerection below the nipple line. Vital signs reveal a blood pressure of 215/115 mmHg and a heart rate of 50 bpm. To immediately reduce the client's risk for a catastrophic physiological complication, which action should the nurse take first?
- Elevate the head of the bed to 90 degrees and assist the client in lowering their legs.Answer
- BPalpate the suprapubic region to assess for urinary retention before adjusting the client's position.
- CMaintain the client in a supine position and prepare a prescribed short-acting intravenous antihypertensive.
- DPrioritize performing a comprehensive neurological assessment to evaluate the extent of cranial nerve involvement.
Answer
The nurse must first elevate the head of the bed to 90 degrees and assist the client in lowering their legs.
The client is exhibiting classic signs of autonomic dysreflexia, a life-threatening hypertensive emergency occurring in clients with spinal cord injuries at or above the T6 level. The massive sympathetic discharge causes severe uncompensated hypertension, which places the client at immediate risk for a hemorrhagic stroke. The absolute first priority to reduce this risk is to leverage gravity by placing the client in a high-Fowler's (90-degree) sitting position. This induces orthostatic pooling of blood in the lower extremities, rapidly decreasing venous return and lowering blood pressure to the brain while the nurse subsequently investigates the underlying cause (most commonly bladder or bowel distention).
Step-by-Step Solution
Key Concept
Immediate risk reduction in Autonomic Dysreflexia prioritizes orthostatic positioning (sitting upright) to lower cerebral blood pressure before identifying and removing the noxious stimulus.
Estimated Time:1m 15s