A client with a complete T4 spinal cord injury reports a sudden, severe, throbbing headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury and obtains a blood pressure reading of 218/114 mm Hg. Arrange the following nursing interventions in the priority order of execution.
- 1Place the client in a high-Fowler's position.
- 2Loosen any restrictive clothing or tight devices.
- 3Assess the indwelling urinary catheter tubing for kinks or obstruction.
- 4Examine the rectum for fecal impaction after applying a topical anesthetic ointment.
- 5Administer the prescribed short-acting antihypertensive medication.
Answer
The correct priority sequence for managing autonomic dysreflexia is to first sit the client upright, then loosen restrictive clothing, identify and correct the most common trigger (bladder), check for the second most common trigger (bowel), and finally administer antihypertensive medication if non-pharmacological measures fail.
Autonomic dysreflexia is a medical emergency characterized by an uninhibited sympathetic response to a noxious stimulus below the level of the spinal cord injury (typically at or above T6). The immediate priority is to lower the blood pressure to prevent a hemorrhagic stroke, which is achieved first by elevating the head of the bed (taking advantage of orthostatic hypotension). The next step is to remove any immediate cutaneous triggers by loosening tight clothing. The nurse must then systematically identify and remove the underlying noxious stimulus. Because bladder distention is the most common cause, assessing the urinary catheter or bladder is the next priority. If the bladder is not the cause, the bowel is assessed for impaction (using anesthetic to prevent further stimulation). Finally, if conservative measures fail to resolve the hypertensive crisis, short-acting antihypertensive medications are administered.
Step-by-Step Solution
Key Concept
Management of autonomic dysreflexia requires immediate positional changes to lower blood pressure, followed by rapid identification and removal of noxious stimuli, beginning with the bladder, then the bowel, prior to pharmacological intervention.