A practical nurse is caring for a client who has a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis above the level of the injury and measures a blood pressure of 210/110 mm Hg. In which order should the nurse perform the following actions? (Arrange the items in the correct sequence, starting with the most immediate priority).
- 1Place the client in a high-Fowler's (sitting) position.
- 2Inspect the indwelling urinary catheter tubing for kinks or obstruction.
- 3Notify the registered nurse (RN) of the assessment findings.
- 4Document the acute event and the client's response to interventions.
Cevap
The correct priority sequence is to first elevate the client's head to a high-Fowler's position, then assess for a triggering stimulus such as a kinked catheter, followed by notifying the registered nurse, and finally documenting the event.
Autonomic dysreflexia is a life-threatening neurological emergency that affects clients with spinal cord injuries at or above the T6 level. The sudden, massive sympathetic response causes severe hypertension. The nurse's absolute first action must be to sit the client upright, which uses gravity to pool blood in the lower extremities and rapidly decrease blood pressure. The next priority is to find and eliminate the cause, which is most often a distended bladder or impacted bowel. Therefore, checking the catheter is the second step. After independent nursing actions are taken to stabilize the client and gather data, the RN is notified. Documentation is always the final step after the emergency is managed.
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Anahtar Kavram
Prioritization of interventions for a client experiencing autonomic dysreflexia, focusing on immediate risk reduction followed by identifying the triggering stimulus.