A postpartum patient with a high spinal cord injury has an indwelling urinary catheter placed for a cesarean birth. The patient's face is red and is complaining of a headache. A current blood pressure measurement is 160/120 mmHg
What should the nurse do first? A) Immediately cut and remove the indwelling catheter.
B) Sit the patient up abruptly and massage the lower back.
C) Raise the head of the bed and assess the catheter for blockage.
D) Lower the head of the bed and coach to breathe slowly in and out.
C
Feedback:
In a patient with a high spinal cord injury, the nurse needs to observe for autonomic dysreflexia during pregnancy, labor, and the immediate postpartum period. This is an exaggerated autonomic response to stimuli. Any irritating condition, such as a distended bladder, may initiate the response. Symptoms include severe hypertension, throbbing headache, and flushing of the skin. Immediate action is needed and includes elevating the patient's head to reduce cerebral pressure and locate the irritating stimulus, which is usually a distended bladder. If bladder distention is the cause and a catheter is in place, check to see why it is not draining and then encourage it to drain by unkinking or flushing to allow urine to flow freely again. As soon as the source of irritation is removed, symptoms typically fade quickly. The indwelling catheter does not need to be removed. Massaging the lower back will not help the symptoms. Lowering the head of the bed could cause the patient to have worsening symptoms.
You might also like to view...
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching?
a. "I should drink bottled water during my travels." b. "I will not eat off another's plate or share utensils." c. "I should eat plenty of fresh fruits and vegetables." d. "I will wash my hands frequently and thoroughly."
An employee has requested special accommodations secondary to a disability. The hospital refuses, citing undue hardship. What must be present for that refusal to be upheld?
1. The accommodation has never been made before this case. 2. The accommodation would require physical changes to the work environment. 3. The accommodation would be very difficult to implement. 4. The accommodation would not be necessary if the employee changed positions.
Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been most effective?
a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I will need to limit my intake of salt and fluids even in hot weather." c. "I will take antibiotics when my teeth are cleaned at the dental office." d. "I should begin an exercise program that includes things like biking or swimming."
What are the two major purposes of providing the community with education? Select all that apply
A) Telling people the best way to find each other after a disaster B) Letting people know the hospital is a place to go for help C) Helping individuals feel more in control D) Helping survivors make telephone calls E) Teaching individuals how to best prepare themselves