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학습 자료 둘러보기 →The first and most critical step is to sit the client upright immediately. This uses orthostatic hypotension to help lower blood pressure and intracranial pressure.
Simultaneously, the priority is to identify and remove the noxious stimulus. The most common cause is bladder distention. Check the urinary catheter for kinks, and if blocked or absent, perform straight catheterization to decompress the bladder.
If the trigger is not urinary, assess for bowel impaction. If suspected, apply a topical anesthetic lubricant before gentle, digital removal to prevent further stimulation.
Monitor blood pressure every 5 minutes. If systolic BP remains above 150 mmHg after removing the stimulus, administer prescribed rapid-onset, short-duration antihypertensives. Do not delay stimulus removal to administer medication.
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