Medical Surgical Spinal Cord Injury #2

Question

The nurse is caring for a client with spinal cord injury and is preparing an instructional plan for the client and family on autonomic dysreflexia. Which teaching promotes the best measure to minimize occurrence of autonomic dysreflexia?

Answers

  1. Perform bladder catheterization once each 12 hours.
    • Rationale:

      This answer is not correct because it is important to keep the client’s bladder from becoming too full, and bladder catheterization once each 12 hours is not frequent enough. A blocked catheter or overfilled collection bag can trigger an autonomic dysreflexia response.

  2. Use nitroglycerin ointment for low blood pressure.
    • Rationale:

      This answer is not correct because nitroglycerin lowers blood pressure. Nitroglycerin is used to decrease blood pressure quickly in clients with autonomic dysreflexia.

  3. Perform range of motion at least 4 times per day.
    • Rationale:

      This answer is not correct because performing range of motion does not lessen the chances of autonomic dysreflexia. Range of motion exercises may also increase blood pressure or potentially cause autonomic dysreflexia.

  4. Perform bladder catheterization at least every 4 hours.
    • Rationale:

      This answer is correct because the most common cause of autonomic dysreflexia is a full bladder. Also, a urinary tract infection can trigger an autonomic dysreflexia response. Performing bladder catheterization at least every 4 hours helps prevent infection and bladder wall irritation. Emptying the bladder also reduces blood pressure.

Overview

Autonomic dysreflexia is when your involuntary nervous system overreacts to stimuli in clients with spinal cord injuries. The nurse should instruct the client and family to make sure the bladder is not full since a full bladder may trigger an autonomic dysreflexia response.

Explanation

Learning Outcomes

Autonomic dysreflexia is a condition seen in spinal cord injuries in which your involuntary nervous system overreacts to stimuli. Autonomic dysreflexia can be easily triggered by things such as bladder distention (most common), urinary tract infection, decubitus ulcers, hemorrhoids, menstruation, sexual intercourse, a sunburn, or even a shoelace tied too tightly. Elevated blood pressure, bradycardia, headaches, and sweating are just a few symptoms of autonomic dysreflexia. Usually, the symptoms subside once the trigger is removed. The nurse should instruct the client and family to make sure the bladder is not full since a full bladder may trigger an autonomic dysreflexia response, which may lead to increased blood pressure and possible stroke.

Test Taking Tip

Break your terms down. “Autonomic” (think involuntary) and “dysreflexia” (think a bad/difficult response). Think of autonomic dysreflexia as an over dramatic response to an otherwise minor stimuli due to a spinal cord injury.

Video Rationale