Question

A T4 lesion client is admitted to the neuro unit. The client suddenly reports a severe pounding headache. Profuse diaphoresis is noted on the forehead. The BP is 180/112 and HR: 56. What interventions should the nurse initiate?

1) Place the client supine with legs elevated
2) Assess bladder and bowel distension
3) Examine skin for pressure sore
4) Eliminate drafts
5) Administer hydralazine if BP does not return to normal

Answer 1

A client with a T4 lesion may be experiencing autonomic dysreflexia. Immediate interventions include assessing for bladder and bowel distension, placing the client in a sitting position, and administering antihypertensive medications such as hydralazine if the BP remains high.

Step-by-step explanation:

A client with a T4 lesion is experiencing a severe pounding headache, profuse diaphoresis on the forehead, elevated blood pressure (BP), and a slow heart rate (HR). These symptoms may indicate autonomic dysreflexia (AD), which is an emergency condition common in patients with spinal cord injuries above T6. The nurse should:

1. Assess bladder and bowel distension - Since these are common triggers for AD, the nurse must assess for and relieve any distention.
2. Place the client in a sitting position to help lower blood pressure.
3. Examine the skin for any pressure sores that could also be contributing to AD.
4. Eliminate drafts or any stimuli that may cause an exacerbation of symptoms.
5. Administer hydralazine or other anti-hypertensive medications if prescribed and BP does not reduce after initial interventions.

Leg elevation is typically not recommended as it can potentially increase blood pressure further. The priority is to address the cause and manage the symptoms of AD.