Medical Surgical Head Injury #3

Question

The nurse is caring for a client with a traumatic brain injury diagnosed with autonomic dysreflexia. The nurse plans to maintain bedrest with:

Answers

  1. The bed in High Fowler’s position
    • Rationale:

      This answer is correct because maintaining the client in high Fowler’s position will keep the blood pressure decreased. Having the legs lowered will cause blood to pool in the lower extremities, further decreasing blood pressure. Autonomic dysreflexia causes severe hypertension and can be fatal if not treated immediately.

  2. The bed in semi-Fowler’s position
    • Rationale:

      This answer is not correct because semi-Fowler’s position is used to promote lung expansion to allow for ventilation and during gastric feedings to reduce the risk for aspiration. The priority of a client with autonomic dysreflexia is to keep blood pressure stabilized and semi-Fowler’s position is not the recommended position for this.

  3. A right-side lying position supported by a pillow
    • Rationale:

      This answer is not correct because a right side-lying position is utilized after a liver biopsy to prevent hemorrhage. This position is called the right lateral position.

  4. Sim’s position with the head of the bed flat
    • Rationale:

      This answer is not correct because keeping the head flat will elevate blood pressure. This position is the client lying on the left side with the right leg bent.

Overview

Autonomic dysreflexia is reported in cases of traumatic brain injury when autonomic activity is altered. It can result in life-threatening hypertension. The client is to maintain bed rest in high Fowler’s position with the legs lowered.

Explanation

Learning Outcomes

Autonomic dysreflexia is reported in cases of traumatic brain injury when autonomic activity is altered. It can result in life-threatening hypertension. For this reason, the client is to maintain bed rest in high Fowler’s position. Keeping the client’s leg lowered also decreases blood pressure. The client sitting straight up, having the legs lowered will cause blood to pool in the lower extremities, further decreasing blood pressure. This is because there is less blood circulating back to your heart. High Fowler’s position will also assist with ventilation and prevent hypertensive stroke.

Test Taking Tip

Remember that keeping the head elevated straight up and legs lowered will decrease blood pressure because there is less blood circulating back to your heart.

Video Rationale