The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Alteration in Perfusion?
Select all that apply.
A) Discuss future care needs when discharged.
B) Increase fluids to 3,000 mL per day.
C) Turn and reposition every 2 hours.
D) Assess for a full bladder.
E) Assess blood pressure every 2-3 minutes.
Answer: D, E
An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 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, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, or an intervention for Alteration in Perfusion. Turning the client every 2 hours is not a priority at this time, or an intervention for Alteration in Perfusion.
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