Question

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

Answer 1

The nurse's appropriate interventions for a patient with a T5 complete spinal cord injury and signs of autonomic dysreflexia include elevating the head of the bed, loosening clothing, using a fan, assessing for bladder and bowel issues, and administering antihypertensive medication.

Step-by-step explanation:

The nurse is caring for a client with a T5 complete spinal cord injury and notices signs that may indicate autonomic dysreflexia: flushed skin, diaphoresis above the level of injury, elevated blood pressure, and a severe headache. Appropriate nursing interventions for this condition include:

• Elevate the head of the bed (HOB) to 90 degrees to help lower blood pressure.
• Loosen constrictive clothing to reduce any stimuli that could be triggering autonomic dysreflexia.
• Use a fan to help with cooling and reduce diaphoresis.
• Assess for bladder distention and bowel impaction, as these are common triggers for autonomic dysreflexia in individuals with spinal cord injury.
• Administer antihypertensive medication as per orders to manage the elevated blood pressure and prevent complications.

These interventions aim to promptly address the symptoms and manage the potentially life-threatening condition of autonomic dysreflexia.