A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis above the level of the injury. The client's blood pressure is 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority from first to last.
- 1Elevate the head of the bed to a high Fowler's position.
- 2Loosen any constrictive clothing on the client.
- 3Assess the urinary system for bladder distention or a kinked catheter.
- 4Administer a prescribed short-acting antihypertensive medication.
Cevap
The correct priority sequence is to first elevate the head of the bed, then loosen constrictive clothing, followed by assessing the urinary system, and finally administering a prescribed antihypertensive medication if needed.
For a client experiencing autonomic dysreflexia, the immediate priority is to prevent a cerebrovascular accident by utilizing gravity to lower the blood pressure. Therefore, elevating the head of the bed is always the first action. Following this, the nurse must systematically search for and remove noxious stimuli, beginning with easily correctable external factors like tight clothing, and then assessing for the most common internal trigger, which is bladder distention. Pharmacological interventions are reserved as a last resort if independent nursing measures do not resolve the crisis.
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Anahtar Kavram
Prioritization of care for autonomic dysreflexia