The nurse caring for a patient with a spinal cord injury notes that the patient is having autonomic dysreflexia. What is the priority nursing action at this time?
A) Irrigate the catheter.
B) Check the rectum for a fecal mass.
C) Place the patient in a sitting position.
D) A topical anesthesia is inserted into the rectum.
Ans: C
Feedback: The following measures are carried out: The patient is placed immediately in a sitting position to lower blood pressure. Rapid assessment is performed to identify and alleviate the cause. The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. The rectum is examined for a fecal mass. If one is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The skin is examined for any areas of pressure, irritation, or broken skin. Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. If these measures do not relieve the hypertension and excruciating headache, a ganglionic blocking agent (hydralazine hydrochloride [Apresoline]) is prescribed and administered slowly by the IV route. The medical record or chart is labeled with a clearly visible note about the risk of autonomic dysreflexia. The patient is instructed about prevention and management measures. Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury.
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