A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis and a blood pressure of 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen any restrictive clothing or devices.
- 3Assess the bladder and bowel for distention or impaction.
- 4Administer a prescribed rapidly acting antihypertensive medication.
Cevap
The correct sequence of actions is to first elevate the head of the bed, then loosen restrictive clothing, followed by assessing for the underlying internal trigger (bladder or bowel), and finally administering antihypertensive medications if the symptoms do not resolve.
In autonomic dysreflexia, the immediate threat to life is severe hypertension, which can cause a stroke. Elevating the head of the bed uses gravity to induce orthostatic hypotension. Next, removing immediate surface triggers like tight clothing prevents further stimulation. Then, the nurse must assess for and resolve the most common internal triggers, such as bladder or bowel distention. Only if these interventions fail should antihypertensive medications be administered.
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Anahtar Kavram
Autonomic dysreflexia is a medical emergency characterized by sudden, severe hypertension. Priority management involves immediate positioning to lower blood pressure, followed by identifying and eliminating the triggering noxious stimulus.