Neurological Disorders Q 108

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A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

  

     A. Strict adherence to a bowel retraining program.

     B. Keeping the linen wrinkle-free under the client.

     C. Preventing unnecessary pressure on the lower limbs.

     D. Limiting bladder catheterization to once every 12 hours.

    

    

Correct Answer: D. Limiting bladder catheterization to once every 12 hours

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The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

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Option A: Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Establish a regular daily bowel program (digital stimulation, prune juice, warm beverage, and use of stool softeners and suppositories at set intervals. Determine usual time and routine of postinjury evacuations.

Option B: Massage and lubricate skin with bland lotion or oil. Protect pressure points by use of heel or elbow pads, lamb’s wool, foam padding, egg-crate mattress. Use skin hardening agents (tincture of benzoin, karaya, Sween cream). Enhances circulation and protects skin surfaces, reducing risk of ulceration. Tetraplegic and paraplegic patients require lifelong protection from decubitus formation, which can cause extensive tissue necrosis and sepsis. Keep bed clothes dry and free of wrinkles, crumbs. Reduces or prevents skin irritation.

Option C: Elevate lower extremities at intervals when in chair, or raise foot of bed when permitted in individual situations. Assess for edema of feet and ankles. Loss of vascular tone and “muscle action” results in pooling of blood and venous stasis in the lower abdomen and lower extremities, with increased risk of hypotension and thrombus formation.

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