A nurse is caring for a client with a complete 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 spinal lesion, accompanied by marked pallor and piloerection below the lesion. The client's blood pressure is mmHg and heart rate is bpm. Place the following nursing interventions in the correct sequence of priority to manage this acute complication.
- 1Elevate the head of the bed to a high-Fowler's position ( degrees) and loosen any constrictive clothing.
- 2Assess the urinary system for distension and relieve the obstruction (e.g., unkink the catheter tubing or perform straight catheterization).
- 3Evaluate for bowel impaction utilizing a topical anesthetic ointment before performing a digital rectal examination.
- 4Administer a prescribed rapid-acting, short-duration antihypertensive medication (e.g., sublingual nitroglycerin or nifedipine).
- 5Document the precipitating trigger, the sequential interventions executed, and the client's hemodynamic and neurological response.
Cevap
The correct sequence is: 1) Elevate the head of the bed, 2) Assess and relieve urinary obstruction, 3) Evaluate for bowel impaction, 4) Administer antihypertensive medication, and 5) Document the event.
The priority in managing autonomic dysreflexia is to rapidly lower the dangerously high blood pressure to prevent a hemorrhagic stroke. Elevating the head of the bed utilizes gravity to induce orthostatic pooling of blood in the lower extremities, providing an instant reduction in blood pressure. Once the client is safely positioned, the nurse must systematically identify and eliminate the noxious stimulus driving the sympathetic surge. Because bladder distension is the most common cause, the urinary system is assessed first. If the bladder is empty, bowel impaction (the second most common cause) is assessed next. If these physical measures fail to resolve the crisis, rapid-acting pharmacological antihypertensives are administered. Finally, once the client is stable, the nurse documents the entire event.
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Anahtar Kavram
Autonomic dysreflexia is a life-threatening sympathetic response in clients with spinal cord injuries at or above . Management requires immediate positioning to lower blood pressure via orthostasis, followed by rapid identification and removal of the noxious stimulus (usually bladder or bowel).