A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the intensive care unit, the patient complains of a severe throbbing headache. What should the nurse do first?
A) Check the patient's indwelling urinary catheter for kinks to ensure patency.
B) Lower the head of the bed to improve perfusion.
C) Call the physician immediately for a pain medication order.
D) Reassure the patient that headaches are normal after spinal cord injuries.
Ans: A
Feedback: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the head of the bed can increase intracranial pressure. Before calling the physician, the nurse should check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient; it isn't normal.
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