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Zorluk: ZorEstablishing Priorities

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of the injury. The client's blood pressure is 210/110210/110 mmHg and heart rate is 5252 beats/min. In what order should the nurse perform the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).

  1. 1Elevate the head of the bed to a high Fowler's position.
  2. 2Inspect the indwelling urinary catheter tubing for kinks or obstruction.
  3. 3Assess the rectum for the presence of a fecal impaction.
  4. 4Administer the prescribed short-acting antihypertensive medication.
  5. 5Document the clinical event, interventions, and client's response.

Cevap

The correct sequence is to first elevate the head of the bed, then assess the urinary catheter for obstruction, followed by checking for a fecal impaction, administering a prescribed antihypertensive medication if symptoms persist, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension and bradycardia in clients with spinal cord injuries at or above T6. The immediate priority is to lower the blood pressure by elevating the head of the bed to a high Fowler's position, which uses orthostatic principles to reduce cerebral pressure. Once the client is repositioned, the nurse must quickly locate and remove the noxious stimulus causing the sympathetic surge. Bladder distention is the most common cause, so checking the catheter for kinks is the second step. If the bladder is not the issue, the nurse checks for bowel impaction, the second most common cause. If these non-pharmacological interventions fail to lower the blood pressure, administering a prescribed rapid-acting antihypertensive is the fourth step. Finally, documenting the critical event is completed after the client is stable.

Adım Adım Çözüm

1
Recognize the clinical signs of autonomic dysreflexia.
The nurse identifies the medical emergency based on the severe headache, hypertension, bradycardia, and diaphoresis in a client with a high spinal cord injury.
Accurate recognition dictates the immediate need for a specific sequence of emergency interventions to prevent stroke.
2
Elevate the head of the bed to 90 degrees.
The client's upper body is positioned upright.
This utilizes gravity to pool blood in the lower extremities, inducing orthostatic hypotension and immediately lowering the dangerously high blood pressure.
3
Identify and remove the noxious stimulus, starting with the urinary system.
The nurse checks the catheter for kinks or assesses for bladder distention.
Bladder distention is the most frequent trigger for autonomic dysreflexia. Resolving it often aborts the crisis.
4
Assess for gastrointestinal triggers if the urinary system is clear.
The nurse performs a rectal examination for fecal impaction.
Bowel impaction is the second most common trigger; it must be assessed if the bladder is not the cause.
5
Administer pharmacologic therapy if conservative measures fail.
The nurse gives a prescribed short-acting antihypertensive medication.
If removing noxious stimuli does not resolve the hypertension, medication is required to prevent a cerebrovascular accident.
6
Document the incident.
The event, interventions, and outcomes are recorded in the client's medical chart.
Documentation provides a legal record and informs the healthcare team, but it is always the final step after client safety is secured.

Anahtar Kavram

Prioritization of interventions for autonomic dysreflexia: Position, find the cause, treat, document.
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Establishing Priorities

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