The nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and profuse diaphoresis above the level of the injury. The blood pressure is 198/104 mm Hg and heart rate is 52 beats per minute. Arrange the following nursing interventions in the correct priority order from first to last.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Assess the urinary catheter for kinks or the bladder for distention.
- 3Notify the healthcare provider of the client's status.
- 4Administer the prescribed short-acting antihypertensive medication.
Cevap
The correct sequence is: Elevate the head of the bed, assess the urinary catheter or bladder, notify the healthcare provider, and administer antihypertensive medication.
The correct sequence prioritizes immediate physiological safety, followed by cause identification, and then medical escalation. Elevating the head of the bed utilizes orthostasis to immediately reduce blood pressure and prevent stroke. Finding and removing the noxious stimulus (commonly bladder distention) treats the root cause. If these measures do not resolve the crisis, the healthcare provider must be notified to provide orders for antihypertensives.
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Anahtar Kavram
Autonomic dysreflexia is a medical emergency characterized by extreme hypertension in clients with spinal cord injuries at or above T6. The immediate priority is placing the client in a sitting position to mechanically lower blood pressure, followed by identifying and removing the noxious stimulus.