A nurse is caring for a client with a complete C7 spinal cord injury who was admitted 3 days ago. The client suddenly develops severe hypertension (BP 190/105 mmHg), bradycardia (HR 52 bpm), profuse diaphoresis above the level of injury, and reports a severe pounding headache. What is the nurse's immediate priority action?
1Check for bladder distention and catheter patency immediately
3Place the client in Trendelenburg position immediately✓ 정답
4Apply oxygen via nasal cannula at 2 L/min
해설
Autonomic dysreflexia presents with hypertension, bradycardia, and headache. Immediate priority is to identify and remove the noxious stimulus, most commonly bladder distention. Other options are incorrect as they do not address the trigger or may be harmful.
Core Nursing ExplanationKey Concept Analysis: This question tests the recognition and immediate management of Autonomic Dysreflexia (AD), a life-threatening emergency specific to patients with a spinal cord injury (SCI) at or above the T6 level. The pathophysiology involves a massive, uninhibited sympathetic nervous system reflex triggered by a noxious stimulus below the level of injury. The stimulus causes vasoconstriction and severe hypertension. The body attempts to compensate via parasympathetic signals (vagus nerve), but these signals cannot descend past the injury, leading to bradycardia and symptoms like headache and diaphoresis above the injury level.
Answer Rationale: The correct answer is Key Point!Check for bladder distention and catheter patency immediately. The immediate priority in AD is to identify and remove the triggering noxious stimulus. The most common trigger is a distended bladder (e.g., from a kinked or blocked Foley catheter). By checking the bladder and catheter first, the nurse is performing the most critical, rapid intervention to potentially resolve the crisis. Administering medication or applying oxygen are secondary actions that do not address the root cause.
Distractor Analysis:
Option ② (Administer antihypertensive medication): This is an important intervention but is not the immediate first action. The priority is to find and remove the stimulus. Medication may be given if symptoms persist after addressing potential triggers.
Option ③ (Place in Trendelenburg position): Watch out for confusion! This is incorrect and dangerous. The correct positional intervention for AD is to sit the patient upright (high Fowler's) to promote orthostatic hypotension and reduce intracranial pressure from the severe hypertension. Trendelenburg (head down) would worsen cerebral hypertension and is contraindicated.
Option ④ (Apply oxygen): While monitoring oxygenation is part of supportive care, applying low-flow oxygen is not the priority intervention for resolving the autonomic crisis itself. The primary threat is the uncontrolled hypertension, not hypoxia.
Related Concepts: AD is a Key Point!NCLEX emergency priority. Remember the mnemonic for common triggers: "Bladder" (most common), "Bowel" (fecal impaction), "Boils" (skin issues like pressure ulcers), "Bones" (fractures), and "Babies" (labor/delivery in pregnant women with SCI).
Concept Summary
Component
Key Information
Condition
Autonomic Dysreflexia (AD) - A medical emergency in SCI at T6 or above.
SCI at T6+, Severe HTN with Bradycardia, Symptoms differ above/below injury level.
Sit up. Find & remove noxious stimulus (e.g., check catheter).
Neurogenic Shock
SCI, especially cervical. Hypotension with Bradycardia & Warm, dry skin (vasodilation).
Lay flat (Trendelenburg may be used). IV fluids. Vasopressors.
Spinal Shock
Immediate post-SCI period. Flaccid paralysis, areflexia, loss of autonomic function below injury.
Immobilization. Supportive care for BP, breathing, bladder/bowel.
Anatomy, Physiology & Pharmacology Points
Anatomy/Physiology: Injuries at T6 or above disrupt the descending inhibitory pathways from the medulla, allowing unchecked sympathetic outflow from the splanchnic nerves (T5-L2). The trigger causes vasoconstriction, raising BP. Baroreceptors in the carotid/aortic arch sense this and try to lower HR via the vagus nerve (parasympathetic), but cannot send signals down to dilate vessels below the injury.
Pharmacology: If hypertension persists after removing stimuli, fast-acting antihypertensives like Nifedipine (sublingual) or Nitroglycerin ointment may be used. These are rapid-acting vasodilators.
Memory Tips
Mnemonic for AD Triggers: "Be Back Before Breakfast, Babe!" = Bladder, Bowel, Boils (skin), Bones, Babies.
Positioning: Think "High Headache needs High Fowler's" (to lower BP in the head). Never put the head down.
High-Frequency NCLEX Topics
Autonomic Dysreflexia is a High Yield topic. The NCLEX loves to test:
1. Recognizing the classic symptom triad (Hypertension + Bradycardia + Headache in an SCI patient).
2. Knowing the immediate first action (sit up, check bladder).
3. Differentiating AD from other types of shock (neurogenic, spinal).
4. Identifying common triggers from a patient scenario.
Watch Out for Question Variations!
Symptom Identification: "A client with a T4 spinal cord injury reports a severe headache and nausea. What should the nurse assess first?" (Answer: Check blood pressure).
Intervention Priority: "After sitting the client upright, which action should the nurse take next?" (Answer: Check for bladder distention/catheter patency).
Patient Education: "The nurse is teaching a client with a C6 SCI about preventing autonomic dysreflexia. Which statement by the client indicates understanding?" (Answer: "I will ensure my indwelling catheter tubing is not kinked.").
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a neuro unit. Mr. Jones, a 24-year-old with a C7 SCI from a diving accident 2 weeks ago, calls you to his room. He is diaphoretic on his face and chest, his face is flushed, and he reports a "crushing" headache. You check his vital signs: BP 210/110 mmHg, HR 48 bpm. He has an indwelling urinary catheter.
Nursing Intervention Strategy:
Immediate Action (First 60 seconds): Call for help. Sit the patient upright immediately (High Fowler's). Do not leave him alone. Loosen tight clothing.
Assessment & Trigger Removal (Next 2-3 minutes):
Bladder: Check the urinary catheter bag. Is it empty? Is the tubing kinked? If the bag is full, empty it. If the catheter is blocked, you may need to irrigate it gently with sterile saline per protocol to restore flow. Do not irrigate forcefully.
If the bladder is not the cause, quickly assess the Bowel: Perform a gentle digital rectal exam (if trained and indicated) to check for fecal impaction. If impaction is found, apply a topical anesthetic gel (e.g., lidocaine) to the rectum before attempting disimpaction to prevent worsening the stimulus.
Skin: Perform a quick head-to-toe skin check below the injury for pressure points, ingrown toenails, or any other source of pain.
Monitoring & Supportive Care: Continuously monitor BP every 2-5 minutes. Notify the physician/provider immediately. Administer prescribed rapid-acting antihypertensive if BP remains dangerously high despite removing stimuli. Apply oxygen if saturations are low. Stay with the patient to provide reassurance and monitor for complications like seizure or stroke.
Prevention & Education: After the crisis, educate the patient and family on AD triggers, symptoms, and the emergency action plan. Emphasize regular bladder/bowel programs, meticulous skin care, and the importance of reporting any unusual symptoms immediately.
Patient Safety and Precautions:
NEVER place the patient in Trendelenburg or a flat position. This increases intracranial pressure.
NEVER ignore a complaint of a headache in an SCI patient above T6. Always check BP.
When checking for bowel impaction, use anesthetic gel to avoid exacerbating the noxious stimulus.
Antihypertensives like nifedipine can cause a rapid drop in BP. Monitor closely.
Nursing Procedure & Medication FlowProcedure: Managing a Blocked Foley Catheter Suspected in AD
Don clean gloves.
Check tubing for kinks. Straighten the tubing and ensure the bag is below bladder level.
If no urine flow, attempt to milk the tubing gently toward the bag.
If still blocked, prepare for irrigation: Don sterile gloves. Use sterile technique. Draw up 30 mL of sterile normal saline into a sterile syringe.
Disconnect the catheter from the drainage bag at the junction port. Insert the syringe tip into the catheter port.
Gently instill the saline. If you meet resistance, stop. Do not force it.
Attempt to withdraw the fluid. If the blockage clears, urine and saline will return. Reconnect to the drainage system.
If irrigation fails, the catheter may need to be replaced. Notify the provider.
NCLEX Point: Often given sublingually for rapid effect in AD. The capsule is punctured and the liquid squeezed under the tongue.
Nursing Alert: Monitor for profound hypotension, reflex tachycardia (may occur after the initial bradycardia resolves), headache, and flushing.
A Word from Your Senior Nurse
"Autonomic dysreflexia is one of those 'don't you dare forget' emergencies in nursing. When you see that combination of high BP and low HR in a spinal cord injury patient, your internal alarm bells should be screaming. In clinical practice, time is brain (and heart!). Your swift action to sit them up and find that kinked catheter or full leg bag can literally be life-saving. On the NCLEX, they're testing your ability to prioritize under pressure. Remember: Treat the cause, not just the numbers. Finding and removing that noxious stimulus is always step one. Master this, and you'll handle this scary scenario with confidence, both on the test and at the bedside."