Question

A client with a high thoracic spinal cord injury develops an episode of autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to: A. Administer an antihypertensive agent B. Notify the physician immediately C. Make sure that the urinary catheter is patent D. Request medication for pain

Short answer

Answer: The most appropriate next action for the nurse is to make sure that the urinary catheter is patent (Option C). This can potentially address the underlying cause of autonomic hyperreflexia and provide immediate relief to the client.

Step-by-step solution

Understand the Situation

Autonomic hyperreflexia is a phenomenon where there is a sudden and exaggerated sympathetic response, especially in patients with spinal cord injuries above T6 level. It can lead to a life-threatening increase in blood pressure. In this exercise, the client has already been placed in high Fowler's position, which helps in improving blood flow and reducing blood pressure. The main focus now should be to identify and address any possible triggers for autonomic hyperreflexia.

Evaluate Option A - Administer an Antihypertensive Agent

Administering an antihypertensive agent can help to control high blood pressure. While it might be important to manage blood pressure during an episode of autonomic hyperreflexia, it is essential first to identify and eliminate the underlying cause to effectively address this condition.

Evaluate Option B - Notify the Physician Immediately

Notifying the physician is an important step. However, since the nurse has already placed the client in a high Fowler's position, addressing the possible underlying cause of autonomic hyperreflexia should be the priority.

Evaluate Option C - Make Sure that the Urinary Catheter is Patent

A common trigger for autonomic hyperreflexia is bladder distension caused by a blocked or kinked urinary catheter. Ensuring that the urinary catheter is patent can address the underlying cause, thus relieving the autonomic hyperreflexia episode. This option seems to be the most appropriate action.

Evaluate Option D - Request Medication for Pain

Although pain may trigger autonomic hyperreflexia, there is no indication in the exercise that the client is experiencing pain. Therefore, this option is not relevant to the given situation.

Choose the Appropriate Next Action

Based on the evaluation of the options, the nurse's next action should be to make sure that the urinary catheter is patent (Option C). This approach can potentially address the underlying cause of the autonomic hyperreflexia and provide the most immediate relief to the client.

Key concepts

Understanding Spinal Cord Injuries

Spinal cord injuries (SCI) are traumatic events that can lead to temporary or permanent changes in sensory, motor, or autonomic function below the level of injury. The severity and location of the SCI significantly influence the patient's symptoms and management strategies.
In the case of autonomic hyperreflexia, a dangerous complication predominantly seen in injuries above the T6 level, the body's response to stimuli below the level of SCI is exaggerated. This can result in life-threatening hypertension, bradycardia, and other autonomic disturbances.

Nursing Assessment

For patients with SCI, comprehensive nursing assessment is paramount. This includes monitoring neurologic status, respiratory function, skin integrity, bowel and bladder function, and potential complications like autonomic hyperreflexia. Identifying signs of autonomic hyperreflexia early is critical, as it can escalate rapidly.

Prevention and Education

Preventing complications begins with education about pressure relief techniques, bowel and bladder management, and recognizing symptoms of potential complications. Patients and caregivers must understand the impact of SCI on the body and how to respond to changes promptly.

Effective Nursing Interventions

Nursing interventions are actions taken by nurses to improve patient outcomes, especially in complex conditions like SCIs. Effective nursing management includes prompt identification and intervention for complications such as autonomic hyperreflexia.
When autonomic hyperreflexia is suspected, nurses must act quickly to raise the head of the bed, as seen in the exercise, and check for common triggers, such as a blocked urinary catheter or bowel impaction. These interventions can rapidly reduce symptoms and stabilize the patient.

Implementation of Care

A multi-pronged approach that includes regular reassessment, catheter care, bowel regimen, and skin care is essential. Nurses should be familiar with emergency protocols for SCI complications and have the ability to perform interventions that might be life-saving for the patient.

Collaboration

Nursing care often involves collaboration with a multidisciplinary team that may include physicians, physical therapists, occupational therapists, and social workers. Coordinated care ensures a holistic approach to patient management.

NCLEX-PN Exam Preparation

Preparing for the NCLEX-PN exam requires a solid grasp of nursing concepts, including the management of spinal cord injuries and autonomic hyperreflexia. A well-rounded study plan should include a review of the pathophysiology, clinical manifestations, and nursing interventions related to SCIs.

Study Resources

Utilize various resources such as textbooks, online courses, and practice questions to cover the breadth of content on the NCLEX-PN exam. Focusing on practice questions similar to the one in the exercise can enhance critical thinking skills and test-taking strategies.

Understand the Rationale

Understanding the rationale behind each intervention is as important as memorizing the steps. When studying, pay particular attention to the 'why' behind actions — this will help in applying knowledge effectively during the actual exam and in clinical practice. Frequent self-assessment can help identify areas needing more focus, ultimately leading to a higher chance of success on the NCLEX-PN exam.