A 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. Limiting bladder catheterization to once every 12 hours.
C. Keeping the linen wrinkle-free under the client.
D. Preventing unnecessary pressure on the lower limbs.
Correct Answer: B. Limiting bladder catheterization to once every 12 hours.
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. 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 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 the usual time and routine of post-injury evacuations.
Option C: Keep bedclothes dry and free of wrinkles, crumbs. Reduces or prevents skin irritation. Wash and dry skin, especially in high moisture areas such as the perineum. Take care to avoid wetting the lining of the brace or halo vest. Clean, dry skin is less prone to excoriation and breakdown.
Option D: Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Reposition frequently, whether in bed or in a sitting position. Place in a prone position periodically. Improves skin circulation and reduces pressure time on bony prominences.
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