A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first?
a. Place the adolescent in a flat right side-lying position.
b. Place a cool washcloth on the adolescent's forehead and continue to monitor the blood pressure.
c. Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter.
d. Take a full set of vital signs and notify the health care provider.
ANS: C
The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Placing a cool washcloth on the adolescent's forehead, continuing to monitor blood pressure and vital signs, and notifying the healthcare provider would not reverse the sympathetic reflex situation.
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