Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?
A.
Administer a prescribed PRN dose of hydralazine.
B.
Assess the client’s blood pressures every 15 minutes.
C.
Teach the client to recognize the symptoms of dysreflexia.
D.
Relieve any kinks or obstruction in the client’s Foley tubing.
The correct answer and Explanation is :
The correct answer is D. Relieve any kinks or obstruction in the client’s Foley tubing.
A client with a C-5 spinal cord injury is at high risk for autonomic dysreflexia (AD), a potentially life-threatening condition. AD occurs in clients with spinal cord injuries at or above the T6 level. It is a result of a noxious stimulus (commonly bladder distension or bowel impaction) that the body can’t properly regulate due to the spinal cord injury. This causes an uncontrolled sympathetic response, leading to symptoms like severe hypertension, headache, flushing, sweating, and bradycardia.
When a client with a C-5 spinal cord injury experiences a flushed appearance and complains of a headache, it is crucial to immediately think of AD. This is a medical emergency because it can quickly lead to complications such as stroke, seizures, or even death if not promptly addressed.
The first intervention is to eliminate the source of the noxious stimulus. A common cause is bladder distension due to a kinked or obstructed urinary catheter. By relieving any kinks or obstructions in the Foley catheter, the stimulus is removed, which can help resolve the dysreflexic episode.
The other options are not appropriate as first interventions:
- A (administering hydralazine): While hydralazine may be prescribed to lower blood pressure, it should not be the first action, as it treats the symptom (hypertension) but not the underlying cause.
- B (assessing blood pressure every 15 minutes): Monitoring blood pressure is essential but should be done after addressing the possible causes.
- C (teaching the client): Education is important for future prevention but not the immediate priority in an acute dysreflexic episode.
In summary, relieving any obstruction in the Foley catheter (D) directly addresses a common trigger of AD, making it the priority intervention in this scenario.