A nurse is caring for a client with a complete T6 spinal cord injury who was admitted 2 days ago. The client suddenly develops severe hypertension (BP 200/110 mmHg), bradycardia (HR 48 bpm), and reports a severe pounding headache. The client appears flushed above the level of injury and pale below. What is the nurse's immediate priority action?
2Place the client in Trendelenburg position to improve circulation
3Elevate the head of the bed and check for bladder distension or bowel impaction✓ 정답
4Apply oxygen via nasal cannula and prepare for emergency intubation
해설
The client shows signs of autonomic dysreflexia (hypertension, bradycardia, headache). Immediate priority is to elevate the head of bed to lower BP and check for triggers like bladder distension or bowel impaction. Other options are incorrect as they do not address the root cause or may worsen the condition.
Clinical Judgment
This question assesses the ability to recognize a life-threatening emergency called Autonomic Dysreflexia (AD) and select immediate nursing interventions based on priority. Two weeks after a spinal cord injury at T6 or above, the patient shows classic AD symptoms: hypertension (200/110 mmHg), bradycardia (48 bpm), headache, flushing above the injury level, and pallor below. The key judgment lies in removing the cause. AD is an exaggerated sympathetic nervous system response to a noxious stimulus below the injury level (most commonly bladder distension). Therefore, the priority is to change the patient's position to lower blood pressure while quickly identifying and removing the most common trigger.
Memory TipHead up, Bladder out!
Remember the priority interventions for AD: High Fowler's position and checking for Bladder distension.
KR vs US
In Korea, immediately reporting to the physician is heavily emphasized, but in NGN/US nursing, the first action the nurse must independently perform right away is considered more important. Reporting is essential, but before waiting for a report, you must start by changing the patient's position and checking for the cause (such as bladder distension).
Clinical Practice GuideAutonomic dysreflexia can occur in patients with spinal cord injury at T6 or above. The triggering stimulus is a visceral or somatic stimulus below the level of injury. The management protocol is as follows:1. Immediately raise the head of the bed to 90 degrees or sit the patient upright.2. Monitor blood pressure.3. Notify HCP!4. Find and remove the triggering stimulus (check in the following order):- Bladder: Check if the catheter is kinked or blocked. Replace the catheter aseptically or perform manual voiding.- Bowel: Check for fecal impaction with a digital rectal exam. Remove the stool using topical anesthetic jelly.- Skin: Check for tight clothing, pressure ulcers, foreign objects under nails, etc.5. If blood pressure remains high after removing the cause, prepare to administer emergency medication (e.g., nifedipine) as prescribed by the physician.
Caution:In SATA (Select All That Apply) questions asking about "management of autonomic dysreflexia," the Trendelenburg position (head lowered) is never included. This position increases cerebral perfusion and can further elevate blood pressure, making it a dangerous intervention. Also, medication administration is the next step when symptoms persist after finding and removing the cause, and it is not the immediate highest priority intervention.
Autonomic Dysreflexia (자율신경 반사부전증) — Life-threatening excessive sympathetic nervous system response in patients with spinal cord injury at T6 or above. Characterized by severe hypertension, bradycardia, headache, and flushing above the level of injury in response to noxious stimuli below the level of injury (e.g., bladder distension).
Spinal Cord Injury (척수 손상) — Injury to the spinal cord caused by trauma or disease. Depending on the level of injury (e.g., T6) and completeness (complete/incomplete), motor, sensory, and autonomic dysfunctions manifest in various ways.
Hypertensive Emergency (고혈압 응급) — A condition where a sudden and severe rise in blood pressure poses an immediate risk of damage to target organs (brain, heart, kidneys). Hypertension in autonomic dysreflexia falls under this category.
Bradycardia (서맥) — A condition in adults where the resting heart rate is below 60 beats per minute. In autonomic dysreflexia, it occurs due to a parasympathetic compensatory response (vagus nerve stimulation) above the level of injury.
Neurogenic Bladder (신경인성 방광) — Bladder dysfunction due to nervous system damage (such as spinal cord injury). This leads to loss of bladder sensation or contractile ability, making it the most common trigger (bladder distension) for autonomic dysreflexia.