Neurological Disorders Q 41

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During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?

  

     A. Elevate the client’s legs.

     B. Put the client flat in bed.

     C. Put the client in Trendelenburg's position.

     D. Put the client in the high-Fowler’s position.

    

    

Correct Answer: D. Put the client in the high-Fowler’s position.

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Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension. Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli.

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Option A: If the trigger cannot be identified and initial maneuvers do not improve the systolic blood pressure below 150 mm Hg pharmacologic management should be initiated. Hypertension should be promptly corrected with agents that have a rapid onset but short duration of action.

Option B: 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 a tetraplegic in a sitting position automatically lowers BP.

Option C: Putting the bed in Trendelenburg’s position places the client in a position that improves cerebral blood flow, worsening hypertension. 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.

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