A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client’s blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take?
A. Loosen tight clothing or accessories
B. Assess for any bladder distention
C. Raise the head of the bed
D. Administer antihypertensive
Correct Answer: C. Raise the head of the bed
The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler’s position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.
Options A & B: After positioning the client in high Fowler’s position, the nurse should remove any noxious stimuli that may trigger autonomic dysreflexia by loosening any tight clothing or objects that might be tight-fitting such as a bracelet, shoes, or stockings and check the bladder if it is too full.
Option D: Antihypertensive medication may be prescribed such as nifedipine and nitrates to decrease cerebral hypertension.
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