A client with a spinal cord injury at the T6 level suddenly develops a pounding headache, profuse sweating above the injury, nasal congestion, and a blood pressure of 180/100 mmHg. Which immediate action should the nurse take?
- APlace the client in a supine position to lower blood pressure.
- BAssess for and alleviate potential noxious stimuli below the injury level.
- CAdminister a prescribed antihypertensive medication.
- DEncourage the client to perform deep breathing exercises.
Show answer & explanationAnswer & explanation
Correct answer: B. Assess for and alleviate potential noxious stimuli below the injury level.
These symptoms are classic signs of autonomic dysreflexia, a life-threatening emergency in clients with spinal cord injuries at T6 or above. It is caused by an exaggerated sympathetic response to noxious stimuli below the level of injury. The immediate priority is to identify and remove the stimulus (e.g., full bladder, fecal impaction, tight clothing, skin breakdown) to prevent further blood pressure elevation and potential complications like stroke.
Why the other options are wrong
- A. Placing the client supine would worsen the blood pressure by increasing cerebral blood flow. The client should be placed in an upright position.
- C. While the blood pressure is high, administering medication without addressing the cause is not the first action and may lead to a hypotensive crisis once the stimulus is removed.
- D. Deep breathing exercises are not sufficient to address the physiological emergency of autonomic dysreflexia.
Autonomic Dysreflexia
A syndrome characterized by a sudden, massive reflex sympathetic discharge in response to stimuli below the level of spinal cord injury (T6 or above), leading to severe hypertension.
- Occurs in spinal cord injury at T6 or higher.
- Symptoms: pounding headache, profuse sweating (above injury), nasal congestion, piloerection, severe hypertension.
- Common triggers: full bladder or bowel, tight clothing, skin irritation.
- Immediate action: elevate head of bed, identify and remove stimulus.
Memory trick: Dysreflexia: Head Pounding, BP Soaring, Find the Trigger!