A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A.
Monitor for elevated blood pressure.
B.
Provide analgesia for headaches.
C.
Prevent bladder distention.
D.
Elevate the client’s head.
The Correct answer and Explanation is:
The correct answer is C. Prevent bladder distention.
Explanation:
Autonomic dysreflexia (AD) is a potentially life-threatening condition often seen in individuals with spinal cord injuries above T-6, but it can occur in those with injuries at or above T-4. It is characterized by an exaggerated autonomic response to noxious stimuli below the level of the injury. Common triggers include bladder distention, bowel impaction, skin irritation, and other sensory inputs.
In patients with spinal cord injuries, the autonomic nervous system can become dysregulated, resulting in a massive sympathetic discharge in response to such stimuli. This can lead to severe hypertension, headaches, sweating, and other distressing symptoms. One of the most common triggers of AD is bladder distention due to urinary retention. Therefore, preventing bladder distention is a crucial intervention for the nurse.
To prevent bladder distention, the nurse should ensure that the client has an appropriate bladder management plan in place, which may include regular catheterization, use of a urinary catheter, or a scheduled toileting program. Monitoring the volume of urine output and promptly addressing any signs of urinary retention can also help mitigate this risk.
While monitoring for elevated blood pressure (option A) and providing analgesia for headaches (option B) are important supportive measures once AD occurs, they do not prevent the onset of the condition. Elevating the client’s head (option D) can help manage symptoms during an episode but does not prevent the underlying causes, such as bladder distention.
In summary, the priority intervention for preventing autonomic dysreflexia in a client with a spinal cord injury at T-4 is to prevent bladder distention by managing the client’s bladder care effectively.