The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD). Which action is most important for the nurse to take first?
a. Elevate the head of the bed.
b. Notify the charge nurse.
c. Decrease the IV fluid rate.
d. Administer antihypertensive medication.
A
AD (hyperreflexia) response is potentially dangerous to the patient, because it can produce va-soconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of bed is the initial intervention to decrease the rising blood pressure. The nurse should notify the charge nurse and the physician. The IV fluids can be decreased but are not the most important intervention. The vital signs should be obtained and the cause of AD should be addressed before administering any hypertensive medication.
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