A nurse is caring for a client who sustained a complete cervical spinal cord injury at the C6 level two months ago. The client suddenly reports an intense, pounding headache and blurred vision. The nurse notes profound diaphoresis on the client's face and neck, nasal congestion, and a blood pressure reading of 214/112 mm Hg. Arrange the following nursing interventions in the correct priority order from first to last to mitigate the risk of severe complications.
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Loosen any constrictive clothing or tight devices.
- 3Assess the urinary drainage system for kinks or obstruction.
- 4Evaluate the rectum for fecal impaction using a topical anesthetic.
- 5Administer the prescribed as-needed intravenous antihypertensive agent.
Cevap
The correct sequence prioritizes immediate physiological safety using gravity to lower blood pressure, followed by the systematic removal of the most statistically probable noxious stimuli, and finally escalating to pharmacological intervention.
In autonomic dysreflexia, a noxious stimulus below the level of the spinal cord injury causes an uninhibited sympathetic response, leading to severe hypertension. The nurse must first lower the blood pressure immediately by sitting the client upright. Next, the nurse must systematically search for and eliminate the trigger, starting with external factors (tight clothing), then the most common internal factor (bladder distention), followed by the next most common (bowel impaction). Antihypertensive medications are a last resort if the trigger cannot be found or resolving it does not lower the blood pressure.
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Anahtar Kavram
Autonomic Dysreflexia Emergency Management
Tahmini Süre:1m 30s