Question

A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:

Notify the physician
Make sure the catheter is patent
Administer an antihypertensive
Provide supplemental oxygen

Answer 1

One of the first nursing interventions to manage autonomic hyperreflexia in a client with a C3 spinal cord injury is placing the client in high Fowler's position. After that, the nurse should make sure the catheter is patent, notify the physician if symptoms persist or worsen, administer an antihypertensive if the blood pressure remains elevated, and provide supplemental oxygen if needed.

Step-by-step explanation:

Autonomic hyperreflexia is a condition that can occur in a client with a C3 spinal cord injury. It is characterized by an overactive sympathetic nervous system response below the level of the injury. One of the first nursing interventions to manage this condition is to place the client in high Fowler's position, which helps to reduce the blood pressure and relieve symptoms. After placing the client in this position, the nurse should then:

1. Make sure the catheter is patent: Autonomic hyperreflexia can be triggered by bladder distention or other causes, so it is important to ensure that the client's urinary catheter is not kinked or blocked.
2. Notify the physician: If symptoms persist or worsen despite interventions, it is important to notify the physician so that further medical management can be implemented.
3. Administer an antihypertensive: If the client's blood pressure remains elevated and other interventions have not been effective, the physician may order an antihypertensive medication to help lower the blood pressure and alleviate symptoms.
4. Provide supplemental oxygen: If the client is experiencing severe symptoms and has low oxygen saturation levels, supplemental oxygen may be necessary to improve oxygenation.