Question

The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next?

A. Notify the health care provider.
B. Check for any kinks in catheter tubing.
C. Have the patient take slow deep breaths.
D. Lower the head of the bed.

Answer 1

The most appropriate action for the nurse to take next is to check for any kinks in the catheter tubing to address a potential trigger for autonomic dysreflexia, and then to notify the health care provider immediately about the patient's condition.

Step-by-step explanation:

A patient with a history of spinal cord injury and an indwelling Foley catheter is presenting with symptoms such as diaphoresis (sweating) and facial flushing, and vital sign measurements show a temperature of 98.4°F, pulse 54, respirations 20, and blood pressure 160/100. These symptoms and vital signs may be indicative of autonomic dysreflexia, a condition that can occur in individuals with spinal cord injuries above T6. Autonomic dysreflexia is a potentially life-threatening medical emergency that is characterized by a sudden onset of excessively high blood pressure. Immediate action is essential.

In this case, the most appropriate first step would be to check for any kinks in catheter tubing. Blockage in the catheter can cause bladder distension, which is a common trigger for autonomic dysreflexia. Following this, it would be critical to notify the health care provider immediately about the patient's condition. While having the patient take slow deep breaths may help with general relaxation, this would not address the potential underlying issue, and lowering the head of the bed could potentially increase the risk of a hypertensive crisis.