A client with a spinal cord injury shows symptoms of autonomic dysreflexia. What is the nurse’s immediate action?

In cases of autonomic dysreflexia, the priority action for the nurse is to raise the head of the bed to a high Fowler position. This position helps lower blood pressure by facilitating venous return and promoting comfort for the client. Autonomic dysreflexia is characterized by a sudden increase in blood pressure due to overactive autonomic responses, often triggered by noxious stimuli below the level of injury. Raising the head of the bed helps to mitigate this spike in blood pressure, making it a critical first step in management.

Furthermore, addressing the position of the patient can provide immediate relief from the symptoms of autonomic dysreflexia, which may include severe headache, flushing, or sweating. This action is part of the supportive measures a nurse can take before more invasive treatments, such as medications or calling the healthcare provider for further instructions, are initiated.

While other actions, such as administering antihypertensive medication or completing a rapid assessment of vital signs, may eventually be appropriate, the first intervention should always be aimed at addressing the high blood pressure situation through positioning.