Question

Patient Profile:

Rehabilitation Phase:

B.V. is now 1 mo postinjury and is currently at a local inpatient SCI rehabilitation facility. He has since been extubated and uses a wheelchair to mobilize. He eats three meals a day with assistance and is on a strict bowel and bladder program.

Subjective Data:

Awake and alert but anxious

Complaining of severe headache, blurred vision, and nausea

Objective Data:

Physical examination

Flushed and diaphoretic above level of injury

No bowel movement for 2 days

BP 235/106mm Hg, pulse 32beats/min, respirations 30breaths/min and labored

Discussion Questions (Rehabilitation Phase)

1. Priority Decision: what initial priority nursing interventions would be appropriate?

Answer 1

Autonomic dysreflexia

It occurs when something happens to your body below the level of your injury. This can be a pain or irritant (such as tight clothing or something pinching your skin) or a normal function that your body may not notice (such as having a full bladder and needing to urinate). These situations trigger an automatic reaction that causes your blood pressure to go up. As your blood pressure goes up, your heartbeat slows and may become irregular. Your body cannot restore your blood pressure to normal because of your spinal cord damage. The only way to return things to normal is to change the situation.

INITIAL PRIORITY IN NURSING INTERVENTIONS

1. In the event of an episode, vital signs should be closely monitored, and recognition of the trigger should be immediately sought.

2. Blood pressure should be checked at least every 5 minutes.

3. Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli.

4. If the trigger cannot be identified and initial maneuvers do not improve the systolic blood pressure below 150 mm Hg pharmacologic management should be initiated. Hypertension should be promptly corrected with agents that have a rapid onset but short duration of action.

5. Loosen or take off any tight clothing or accessories.

6. Bladder and bowel distension are the most common causes. Therefore, restoring bladder drainage is immediately recommended. If the patient has an indwelling catheter, it should be evaluated for malfunction or malpositioning, and a workup for a urinary tract infection should also be performed.

7. On physical examination clearly visible that no bowel movement for 2 days hence a rectal exam should be performed to evaluate for impaction; however, this should be done with care as it can precipitate a worsening crisis due to the stimulation of the procedure.

8. Check the skin for the red spot that means you have a pressure injury.

9. Go to an emergency room or call emergency service.