For a 65-year-old woman who has lived with a T1 spinal cord injury for 20 years, which health teaching instructions should the nurse emphasize?

In a patient with a spinal cord injury at or above T6, sudden severe headache and nausea are hallmark signs of autonomic dysreflexia, a life-threatening emergency caused by an exaggerated sympathetic response to noxious stimuli (such as bladder distention, fecal impaction, or skin irritation). The nurse’s first action is to check the patient’s blood pressure to confirm the diagnosis, since autonomic dysreflexia results in severe hypertension.

Rationale for correct answer:
3. Take the patient’s blood pressure. Confirms whether the symptoms are due to autonomic dysreflexia by detecting dangerous hypertension, which requires immediate intervention.

Rationale for incorrect answers:
1. Call the physician. Contacting the provider is important but not the first action—the nurse must first assess the patient’s BP to confirm the condition.
2. Check the patient’s temperature. Headache and nausea are not early signs of infection in this context; checking temperature delays recognition of a true emergency.
4. Elevate the head of the bed to 90 degrees. This is an essential intervention to lower blood pressure, but assessment (BP check) must be done first to confirm the cause of symptoms.

Take-home points:

• Autonomic dysreflexia presents with severe headache, nausea, flushing, bradycardia, and hypertension in SCI patients at or above T6.
• First priority is to check blood pressure to confirm the condition.
• Once confirmed, the nurse elevates the HOB, removes noxious stimuli, and notifies the physician.

A C4 spinal cord injury can result in paralysis of the diaphragm and intercostal muscles, which significantly compromises respiratory function. The greatest risk is respiratory compromise, which can lead to hypoventilation, hypoxia, and potential respiratory failure. Maintaining airway patency and monitoring respiratory status are top priorities in acute care.

Rationale for correct answer:
4. Respiratory compromise. C4 injuries impair diaphragmatic and accessory muscle function, making the patient highly dependent on ventilatory support. Early recognition of respiratory difficulty and timely interventions are critical to prevent life-threatening complications.

Rationale for incorrect answers:
1. Neurogenic shock. While possible in high-level SCI, neurogenic shock typically occurs acutely and is managed; it is not as immediately life-threatening as respiratory compromise in C4 injuries.
2. Paralytic ileus. Paralytic ileus is more common in thoracic and lumbar injuries; it is secondary in priority to airway and breathing concerns.
3. Stress ulcer. Stress ulcers are a potential complication but develop later and are not an immediate threat to life compared with respiratory failure.

Take-home points:

• C4 SCI patients are at highest risk for respiratory compromise due to diaphragmatic paralysis.
• Continuous monitoring of oxygenation, ventilation, and airway is essential.
• Early intervention with mechanical ventilation or suctioning may be required to maintain life-sustaining respiration.