A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN measures the client's blood pressure at 218/114 mm Hg and notes profuse diaphoresis above the level of the injury. Arrange the following nursing actions in the priority order the PN should perform them to minimize the risk of a cerebrovascular complication.
- 1Elevate the head of the bed to a high-Fowler's or sitting position.
- 2Loosen any tight clothing, restrictive binders, or anti-embolism stockings.
- 3Assess the urinary catheter tubing for kinks or dependent loops.
- 4Notify the registered nurse (RN) or healthcare provider.
- 5Document the clinical findings, interventions performed, and client response.
Cevap
The correct sequence is to first elevate the head of the bed, then loosen restrictive clothing, followed by assessing the urinary catheter, notifying the RN, and finally documenting the event.
In autonomic dysreflexia (a medical emergency in clients with spinal cord injuries at T6 or above), noxious stimuli below the injury cause an uninhibited sympathetic response, leading to severe hypertension. The absolute first priority is to place the client in a high-Fowler's or sitting position to induce orthostatic hypotension and rapidly lower the blood pressure, reducing the risk of a stroke. Next, the nurse should quickly remove any restrictive clothing that might act as a cutaneous stimulus. The third step is to check for the most common cause of the syndrome: bladder distension (e.g., checking for a kinked catheter). Once initial independent steps are taken, the PN must escalate care by notifying the RN or provider, especially if the blood pressure remains elevated and requires medication. Documentation is always the final step in the sequence.
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Anahtar Kavram
Prioritization in Autonomic Dysreflexia: Position, Stimulus Removal, Escalation