The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which of the following interventions would be appropriate for the nursing diagnosis of autonomic dysreflexia?
1. Assess blood pressure every 2 to 3 minutes
2. Assess for a full bladder
3. Discuss future care needs when discharged
4. Turn the client every 2 hours
1. Assess blood pressure every 2 to 3 minutes
Rationale:
Autonomic dysreflexia is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2 to 3 minutes in addition to elevating the head of the bed, and removing TED hose to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for the stimuli which caused the episode, one being a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for dysreflexia. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for dysreflexia.
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