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Zorluk: KolayPhysiological Adaptation

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and exhibits profuse diaphoresis. The client's blood pressure is 210/110 mm Hg210/110 \text{ mm Hg}. Arrange the following nursing actions in the correct priority sequence.

  1. 1Elevate the head of the bed to a high Fowler's position.
  2. 2Assess the urinary catheter tubing for kinks or obstruction.
  3. 3Administer a prescribed short-acting antihypertensive medication.
  4. 4Document the incident, the interventions provided, and the client's response.

Cevap

The correct priority sequence is to first elevate the head of the bed, then assess the urinary catheter, followed by administering antihypertensive medication if needed, and finally documenting the event.
In the management of autonomic dysreflexia, the immediate priority is to lower the blood pressure to prevent a stroke by elevating the head of the bed. The nurse must then find and eliminate the cause (most often a full bladder or bowel impaction). If these measures fail, medications are administered. Documentation is always the final step.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
Decreases venous return to the heart and lowers blood pressure via orthostasis.
This is the most rapid, non-pharmacological way to lower the blood pressure and prevent a cerebral hemorrhage during autonomic dysreflexia.
2
Assess the urinary catheter tubing for kinks or obstruction.
Identifies and potentially resolves the most common trigger (bladder distension).
Autonomic dysreflexia is triggered by a noxious stimulus below the level of the spinal cord injury; removing it often resolves the crisis.
3
Administer a prescribed short-acting antihypertensive medication.
Lowers blood pressure pharmacologically.
Required if the noxious stimulus cannot be found or if blood pressure remains dangerously high despite removing the stimulus.
4
Document the incident, the interventions provided, and the client's response.
Maintains an accurate legal and medical record.
Documentation should always occur after the client is stable and acute life-saving measures have been completed.

Anahtar Kavram

Prioritization in Autonomic Dysreflexia
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Konular

Physiological Adaptation

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