A practical nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and blurred vision. The nurse notes that the client's face is flushed and profusely sweating. In which order should the practical nurse prioritize the following actions? (Arrange from first action to last action)
- 1Elevate the head of the bed to a high Fowler's position.
- 2Measure the client's current blood pressure.
- 3Examine the urinary catheter tubing for kinks or blockages.
- 4Notify the registered nurse or healthcare provider of the findings.
- 5Document the vital signs, nursing interventions, and client's response.
Cevap
The correct sequence of actions for a client experiencing autonomic dysreflexia is to first elevate the head of the bed, then measure the blood pressure, followed by assessing the urinary catheter for blockages, notifying the registered nurse, and finally documenting the event.
Autonomic dysreflexia is a life-threatening neurological emergency characterized by severe hypertension, triggered by a noxious stimulus below the level of the spinal cord injury (typically T6 or higher). The absolute priority is to immediately lower the blood pressure by utilizing orthostatic hypotension, which is achieved by sitting the client upright. Once the immediate risk is slightly mitigated through positioning, the nurse must assess the blood pressure to establish a baseline. Following assessment, the nurse must systematically hunt for and remove the triggering stimulus (most commonly a full bladder or kinked urinary catheter). After these independent actions are taken, the RN or provider must be notified for further collaborative orders, and finally, all findings and actions are documented in the client's medical record.
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Prioritization of Care for Autonomic Dysreflexia