A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
Rationale: This client is experiencing autonomic dysreflexia, which requires immediate treatment to prevent hypertensive stroke. Placing the client in the high Fowler’s position reduces blood pressure by promoting gravitational pooling of blood in the lower extremities. The nurse should notify the health care provider immediately and assess for the cause. Bladder distention and fecal impaction are common causes; if the client has a urinary catheter in place, the nurse should check for kinks in the tubing. If indicated, preparation to catheterize the client should begin immediately. Nitrate or nifedipine are the most common drugs used for treatment.
