Recognizing autonomic dysreflexia
A client with a spinal cord injury at T6 or above who develops a sudden pounding headache, a blood pressure far above his usual (184/100 mmHg versus 104/64 mmHg), and a slow heart rate (52/min) is having autonomic dysreflexia. A noxious stimulus below the injury triggers a massive sympathetic response that constricts blood vessels below the level. The brain senses the hypertension and slows the heart through the vagus nerve, but it cannot send signals down past the injury to relax the vessels. The rise in pressure can cause stroke, seizures, or death, so it is an emergency. His nearly empty urine bag over 3 hours points to the most common trigger: a blocked catheter and distended bladder.
The correct sequence: 3, 1, 4, 2
Sit him upright with the legs lowered first, because this lowers blood pressure at once by pooling blood in the legs. Then loosen clothing and leg-bag straps, which removes quick, easy triggers and takes only seconds. Next, check the catheter tubing for kinks and irrigate it if blocked, because the bladder is the most common cause and emptying it often ends the episode. Only if systolic pressure stays at or above 150 mmHg after the bladder is managed does the nurse apply the ordered nitroglycerin paste above the injury level. The stem tells you to assume the pressure stays high, so the drug comes last.
| Step | Action | Why at this point |
|---|
| 1st | Sit upright, legs lowered | Immediate drop in blood pressure |
| 2nd | Loosen clothing and straps | Fast removal of simple triggers |
| 3rd | Check and clear the catheter | Most common cause |
| 4th | Nitroglycerin paste if systolic stays ≥150 mmHg | Drug only after the cause is addressed |
Why the other orders are wrong
Any sequence that begins with checking the catheter or loosening clothing delays the single fastest way to lower pressure, which is sitting the client up. Starting with loosening clothing while he is still lying flat leaves the pressure high longer. The drug never comes first because removing the trigger often resolves the episode, and the order is written for pressure that persists after the bladder is managed. The stem also notes that he has not taken a phosphodiesterase-5 inhibitor; this matters because nitrates are contraindicated with those drugs.
After the bladder
If the bladder is not the cause or pressure stays high, the nurse checks the bowel for impaction, using lidocaine gel before rectal examination. Blood pressure is monitored every few minutes, the episode and its trigger are documented, and the client and family are taught to recognize and manage future episodes.
Exam takeaway
Key point Autonomic dysreflexia: sit up first, remove triggers, check the bladder, then the bowel, and use ordered antihypertensives if pressure stays high.