A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck.
A. Administer the ordered acetaminophen (Tylenol). B. Check the Foley tubing for kinks or obstruction. C. Adjust the temperature in the patientâ€™s room. D. Notify the physician about the change in status.
A patient who has a spinal cord injury is a risky patient because severing the spinal cord could cause paralysis or death. Even the slightest injury to the spinal cord could cause these problems. Therefore, the nurse should watch after the patient. Also, the nurse should monitor other signs because different problems could take place.
The patient could have problems with his blood pressure, heart rate and flushing of the face and neck. If the patient had increased blood pressure and a decreased heart rate coupled with the flushing of the face and neck, the nurse should check the Foley tubing for kinks or obstruction because this tubing that does not allow anything to flow to the body could result in these problems.
Check the foley tubing for kinks or obstruction. -these signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. the cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. tylenol will not decrease the autonomic dysreflexia that is causing the patients headache. notification of the physician may be necessary if nursing actions do not resolve symptoms. focus: prioritization