# A nurse is caring for a client with a complete T6 spinal cord injury who is experiencing autonomic dysreflexia. The client's blood pressure is 200/110 mmHg, and they are complaining of a severe headache and profuse sweating above the level of injury. What is the nurse's priority intervention?

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## 문제

A nurse is caring for a client with a complete T6 spinal cord injury who is experiencing autonomic dysreflexia. The client's blood pressure is 200/110 mmHg, and they are complaining of a severe headache and profuse sweating above the level of injury. What is the nurse's priority intervention?

## 보기

1. Administer prescribed antihypertensive medication immediately
2. Sit the client upright and check for bladder distention or bowel impaction **✔ 정답**
3. Apply cool compresses to the client's forehead and neck
4. Notify the physician and prepare for emergency intubation

**정답: 2**

## 해설

The priority is to sit the client upright to lower blood pressure and then identify/remove the noxious stimulus, typically bladder distention. Administering antihypertensives or other measures without addressing the cause is incorrect.

## 심화 해설

Understanding Autonomic Dysreflexia (AD)

Autonomic dysreflexia is a life-threatening emergency unique to individuals with spinal cord injuries at or above the T6 level. As described in the literature, a high-level SCI disrupts the normal descending control of the sympathetic nervous system [2]. In a complete T6 injury, a noxious stimulus below the level of injury triggers a massive, unopposed sympathetic reflex. This leads to severe paroxysmal hypertension, which is the hallmark of AD and can directly precipitate cerebrovascular events such as intracerebral hemorrhage [1].

Analyzing the Clinical Presentation

The client's blood pressure of 200/110 mmHg represents a hypertensive crisis. The severe headache is a classic symptom resulting from the rapid rise in blood pressure and cerebral vasodilation. The profuse sweating above the level of injury is the body's intact parasympathetic response attempting to compensate for the sympathetic storm below the lesion. The combination of these symptoms in a client with a T6 SCI is a clear, textbook presentation of AD.

Establishing the Priority Intervention

The nurse's immediate priority is to identify and remove the triggering stimulus to rapidly lower the blood pressure. The most common triggers are distention of a hollow organ, such as the bladder or bowel. Sitting the client upright is the first critical action; this uses orthostatic hypotension to help lower the intracranial pressure and blood pressure. Simultaneously, the nurse must immediately check for and relieve bladder distention (e.g., a kinked Foley catheter) or bowel impaction. This sequence addresses the root cause of the sympathetic discharge, which is the most effective way to resolve the episode.

Why Other Options Are Not the Priority

- Administering prescribed antihypertensive medication is an important intervention, but it is not the first step if a reversible cause like bladder distention can be quickly identified and corrected. Medication is reserved for situations where removing the stimulus does not promptly lower the blood pressure.

- Applying cool compresses is a comfort measure that does not address the life-threatening hypertension or its underlying cause.

- Notifying the physician and preparing for emergency intubation is premature. Intubation is not a standard treatment for AD. The immediate, nurse-driven actions of positioning the client and checking for common noxious stimuli are the established first-line interventions that can rapidly resolve the crisis and prevent the progression to severe complications like the recurrent cerebral hemorrhage highlighted in the case report [1].References (research sources)

- [1]Autonomic dysreflexia: the concealed killer behind recurrent cerebral hemorrhage in spinal cord injury-a case report with management insights.Case reportTang N, Zheng B, Ni J, Xie Y, Zhang L, Han Q, Sun L. (2026) · DOI: 10.3389/fnins.2026.1800186

- [2]Effects of non-invasive spinal cord stimulation on autonomic function in individuals with subacute spinal cord injury: A pilot clinical trial protocol.RCT/clinical trialNakahara R, Nasson S, Bieler E, Putsche-Young E, Aguila B, Shen J, Chung E, Winston L, Burns S, Crane D, Eugenio M, Krogh K, Krassioukov A, Moritz C, Samejima S. (2026) · DOI: 10.1371/journal.pone.0347211

## 임상 시나리오

Autonomic Dysreflexia: Immediate Nursing ActionRapid Identification and Removal of the Triggering Stimulus
The first and most critical step is to sit the client upright immediately. This uses orthostatic hypotension to help lower blood pressure and intracranial pressure.

Simultaneously, the priority is to identify and remove the noxious stimulus. The most common cause is bladder distention. Check the urinary catheter for kinks, and if blocked or absent, perform straight catheterization to decompress the bladder.

If the trigger is not urinary, assess for bowel impaction. If suspected, apply a topical anesthetic lubricant before gentle, digital removal to prevent further stimulation.

CautionMonitor blood pressure every 5 minutes. If systolic BP remains above 150 mmHg after removing the stimulus, administer prescribed rapid-onset, short-duration antihypertensives. Do not delay stimulus removal to administer medication.

## 핵심 개념

- **Autonomic Dysreflexia** — A life-threatening emergency in SCI patients at T6 or above, characterized by an exaggerated sympathetic response to a noxious stimulus below the injury level, leading to severe hypertension.
- **Noxious Stimulus** — An irritating or painful stimulus below the level of SCI, most commonly bladder distention or bowel impaction, that triggers the autonomic dysreflexia cascade.
- **Orthostatic Hypotension** — A drop in blood pressure upon sitting or standing; in AD management, sitting the patient upright utilizes this effect to help lower blood pressure immediately.

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