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학습 자료 둘러보기 →The hallmark of autonomic dysreflexia is a sudden, severe hypertension (BP may reach 180/110 mmHg or higher) with a pounding headache and diaphoresis above the level of injury. This is a medical emergency.
Immediate nursing action is to elevate the head of the bed to 90 degrees and lower the legs to promote orthostatic pooling of blood. Simultaneously, the noxious stimulus must be identified and removed; the most common trigger is bladder distention.
Never ignore a complaint of headache in a patient with a high-level SCI. Monitor BP every 2-5 minutes until stabilized. If symptoms persist after removing the stimulus, administer prescribed rapid-acting antihypertensives while continuing to search for the cause.
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