A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
A. Place the client flat in bed.
B. Assess patency of the indwelling urinary catheter.
C. Give one SL nitroglycerin tablet.
D. Raise the head of the bed immediately to 90 degrees.
Correct Answer: D. Raise the head of the bed immediately to 90 degrees.
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing tetraplegic in sitting position automatically lowers BP.
Option A: Putting the client flat will cause the blood pressure to increase even more. Identify and monitor precipitating risk factors (bladder and bowel distension or manipulation; bladder spasms, stones, infection; skin/tissue pressure areas, prolonged sitting position; temperature extremes or drafts). Visceral distention is the most common cause of autonomic dysreflexia, which is considered an emergency. Treatment of acute episodes must be carried out immediately (removing stimulus, treating unresolved symptoms), then interventions must be geared toward prevention.
Option B: The indwelling urinary catheter should be assessed immediately after the HOB is raised. Eliminate causative stimulus as able such as bladder, bowel, skin pressure (including loosening tight leg bands or clothing, removing abdominal binder or elastic stockings); temperature extremes. Removing noxious stimulus usually terminates the episode and may prevent more serious autonomic dysreflexia (in the presence of sunburn, topical anesthetic should be applied).
Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia. Monitor BP frequently (every 3–5 min) during acute autonomic dysreflexia and take action to eliminate stimulus. Continue to monitor BP at intervals after symptoms subside. Aggressive therapy and removal of stimulus may drop BP rapidly, resulting in a hypotensive crisis, especially in those patients who routinely have low BP.
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