The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
A. Elevate the HOB to 90 degrees.
B. Loosen constrictive clothing.
C. Use a fan to reduce diaphoresis.
D. Assess for bladder distention and bowel impaction.
E. Administer antihypertensive medication.
F. Place the client in a supine position with legs elevated.
Correct Answer: A, B, D, & E
The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system.
Option A: The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. 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 B: Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. Removing noxious stimulus usually terminates the episode and may prevent more serious autonomic dysreflexia (in the presence of sunburn, topical anesthetic should be applied). Removal of constrictive clothing and vascular support also promotes venous pooling to help lower BP.
Option C: A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia. 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).
Option D: The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. 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.
Option E: Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. 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.
Option F: Early detection and immediate intervention is essential to prevent serious consequences and complications. Note: Average systolic BP in a tetraplegic patient is 120, therefore readings of 140+ may be considered high.
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