A nurse is caring for a client with a complete T6 spinal cord injury who was admitted 2 weeks 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 priority action?
2Place the client in high Fowler's position and check for bladder distention✓ 정답
3Apply oxygen via nasal cannula and prepare for emergency intubation
4Notify the physician immediately and prepare emergency medications
해설
Autonomic dysreflexia is a medical emergency requiring immediate identification and removal of the triggering stimulus. Placing the client in high Fowler's position and checking for bladder distention addresses the hypertension and common cause, while other options delay or are less direct interventions.
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).
임상 시나리오
Clinical Practice Guide
1. Immediate Action: Sit the patient in high Fowler's position (close to 90 degrees) with legs dependent. This reduces cerebral blood flow via gravity, lowering blood pressure and decreasing stroke risk.
2. Identify and Remove Cause: Check for bladder distention first. If a urinary catheter is present, ensure it is not blocked; if absent, perform immediate intermittent catheterization. If the bladder is not the cause, next check for fecal impaction (digital rectal exam), pressure injuries, tight clothing, or foreign bodies under nails.
3. Report to Physician and Prepare Medications: While performing the above interventions, simultaneously report to the physician. If blood pressure persists after removing the cause, prepare to administer nitroglycerin ointment or other antihypertensives as prescribed by the physician.
Caution
In SATA (Select All That Apply) questions, "Notify the HCP" is almost always included in the correct answer, but in single-answer multiple-choice questions, a specific independent nursing action that can be taken immediately has higher priority. While "reporting to the physician" is essential, the patient's condition may deteriorate while 'waiting' for the report, so you must select the direct intervention to be performed simultaneously with or before the report.
핵심 개념
Autonomic Dysreflexia — In patients with spinal cord injury at T6 or above, this is an excessive sympathetic nervous system response to harmful stimuli below the injury level (such as bladder distension, bowel obstruction, etc.), characterized by life-threatening hypertension, bradycardia, headache, sweating, and flushing—a medical emergency.
Spinal Cord Injury — Injury to the spinal cord caused by trauma or disease. Depending on the location and completeness (complete/incomplete) of the injury, motor, sensory, and autonomic dysfunctions manifest in various ways.
High Fowler's Position — Positioning the patient's head and upper body elevated 60-90 degrees from the bed. This uses gravity to promote diaphragm descent and, during autonomic dysreflexia, reduces blood flow to the brain to lower blood pressure.
Bladder Distention — A condition where the bladder is excessively distended with urine. It is the most common cause (85-90%) of autonomic dysreflexia in patients with spinal cord injury, and must be resolved immediately through catheterization.
Bradycardia — In a normal adult, a state where the heart rate is less than 60 beats per minute. In autonomic dysreflexia, it is one of the typical signs that occurs as a compensatory mechanism for hypertension, triggered by the baroreceptor reflex in the carotid sinus and aortic arch.