A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess for which precipitating factor?

A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess for which precipitating factor?

• A. An acutely distended bladder.
• B. Profuse forehead diaphoresis.
• C. Skeletal traction misalignment.
• D. A severe pounding headache.

Answer: (A)

Autonomic dysreflexia is triggered when a noxious stimulus below the level of injury sends an unregulated sympathetic surge, leading to a dangerous rise in blood pressure. The most common precipitating factor in someone with a high spinal cord injury is bladder distention from a full or obstructed catheter. Therefore, the first assessment is to determine whether the bladder is distended or the catheter is blocked and relieve that obstruction promptly by draining the bladder. After addressing the bladder, continue to monitor blood pressure and look for other potential triggers, such as stool or skin irritation. Symptoms like profuse forehead sweating or a pounding headache are signs of the crisis, not the initial trigger, and while skeletal traction misalignment can be a trigger, bladder distention remains the most frequent first suspect.

Autonomic dysreflexia is triggered when a noxious stimulus below the level of injury sends an unregulated sympathetic surge, leading to a dangerous rise in blood pressure. The most common precipitating factor in someone with a high spinal cord injury is bladder distention from a full or obstructed catheter. Therefore, the first assessment is to determine whether the bladder is distended or the catheter is blocked and relieve that obstruction promptly by draining the bladder. After addressing the bladder, continue to monitor blood pressure and look for other potential triggers, such as stool or skin irritation. Symptoms like profuse forehead sweating or a pounding headache are signs of the crisis, not the initial trigger, and while skeletal traction misalignment can be a trigger, bladder distention remains the most frequent first suspect.