# A nurse is assessing a patient with a complete T6 spinal cord injury who was admitted 2 weeks ago. Which assessment finding would be most concerning and require immediate intervention?

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## 문제

A nurse is assessing a patient with a complete T6 spinal cord injury who was admitted 2 weeks ago. Which assessment finding would be most concerning and require immediate intervention?

## 보기

1. Blood pressure 90/60 mmHg with heart rate 58 bpm and dizziness on sitting
2. Blood pressure 180/110 mmHg with severe headache and diaphoresis above the level of injury **✔ 정답**
3. Absence of sensation and voluntary movement below the nipple line with flaccid paralysis
4. Bladder distention with 400 mL of urine via catheter drainage and lower abdominal discomfort

**정답: 2**

## 해설

Blood pressure 180/110 mmHg with severe headache and diaphoresis above the level of injury indicates autonomic dysreflexia, a life-threatening emergency in spinal cord injuries above T6 requiring immediate intervention. Other findings are expected or less critical in this context.

## 심화 해설

Understanding the Priority: Recognizing Autonomic Dysreflexia

The patient has a complete T6 spinal cord injury, which places them at significant risk for autonomic dysreflexia (AD). This condition is a medical emergency because it represents a life-threatening, unmodulated sympathetic nervous system response to a noxious stimulus below the level of injury [1,2]. The most concerning finding requiring immediate intervention is a critically high blood pressure accompanied by a severe headache and diaphoresis above the injury level.

Analysis of the Correct Answer (Option 2)

A blood pressure of 180/110 mmHg with a severe headache and diaphoresis above the T6 level is the classic clinical presentation of autonomic dysreflexia. The pathophysiology involves a noxious stimulus, such as bladder distention or bowel impaction, triggering afferent sensory signals that cannot be modulated by the brain due to the spinal cord lesion [2]. This results in massive sympathetic hyperactivity below the injury, causing severe vasoconstriction and a paroxysmal spike in blood pressure. The body’s compensatory response, mediated by the baroreceptors and vagus nerve, leads to bradycardia and vasodilation above the injury level, manifesting as a pounding headache and profuse sweating [1,4]. This hypertensive crisis carries a high risk of devastating complications, including cerebral or retinal hemorrhage, seizures, heart failure, and pulmonary edema, necessitating immediate intervention to identify and remove the triggering stimulus [2,3].

Analysis of Incorrect Options

- Option 1: A blood pressure of 90/60 mmHg with a heart rate of 58 bpm and dizziness upon sitting is a concerning finding, but it is an expected manifestation of neurogenic shock in the acute phase of a spinal cord injury. This condition results from the loss of sympathetic tone, leading to hypotension and bradycardia. While requiring careful management, it does not present the same immediate, life-threatening danger of a cerebral hemorrhage as the hypertensive crisis in option 2.

- Option 3: The absence of sensation and voluntary movement below the nipple line with flaccid paralysis is an expected neurological finding for a complete T6 injury. This represents the baseline motor and sensory deficit and is not an acute, newly emergent condition requiring immediate intervention.

- Option 4: Bladder distention with 400 mL of urine and lower abdominal discomfort is a critical clue, as it is the most common noxious stimulus that triggers an AD episode. However, the finding itself is the potential cause of the emergency, not the most concerning manifestation of it. The nurse’s immediate priority is to address the life-threatening hypertension described in option 2, with the subsequent step being a rapid assessment for the triggering cause, such as this bladder distention [1].References (research sources)

- [1]Spinal Cord Injury and Autonomic Dysreflexia: A Case Report on an Overlooked Complication of Spinal Cord Injury.Case reportAlwashmi AH. (2022) · DOI: 10.7759/cureus.30259

- [2]Autonomic Dysreflexia following Spinal Cord Injury.Research articleBalik V, Šulla I. (2022) · DOI: 10.1055/s-0042-1751080

## 임상 시나리오

Autonomic Dysreflexia: Emergency ManagementLife-Threatening Hypertensive Crisis in SCI Patients
The hallmark of autonomic dysreflexia is a sudden, severe hypertension (BP may reach 180/110 mmHg or higher) with a pounding headache and diaphoresis above the level of injury. This is a medical emergency.

Immediate nursing action is to elevate the head of the bed to 90 degrees and lower the legs to promote orthostatic pooling of blood. Simultaneously, the noxious stimulus must be identified and removed; the most common trigger is bladder distention.

CautionNever ignore a complaint of headache in a patient with a high-level SCI. Monitor BP every 2-5 minutes until stabilized. If symptoms persist after removing the stimulus, administer prescribed rapid-acting antihypertensives while continuing to search for the cause.

## 핵심 개념

- **Autonomic Dysreflexia** — A life-threatening medical emergency in patients with SCI at or above T6, characterized by an unopposed sympathetic response causing severe hypertension, headache, and diaphoresis.
- **Spinal Shock** — A temporary period of areflexia and flaccid paralysis below the level of injury immediately following SCI, which can last days to weeks.
- **Orthostatic Hypotension** — A drop in blood pressure upon position change, common in SCI due to loss of sympathetic vasoconstriction, presenting with dizziness but not typically a hypertensive crisis.
- **Noxious Stimulus** — An irritating or painful stimulus below the level of injury, such as a full bladder or bowel impaction, which is the most common trigger for an autonomic dysreflexia episode.

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