1000: The client is 14 days post motor vehicle collision with complete T4 spinal cord injury. Client is off the unit with PT/OT for evaluation.
1115: Client returned to room. The client states he feels tired after therapy and requests to be transferred to bed. The client suddenly reports, “I have a pounding headache.” The client rates the headache as 8/10. He appears irritable and requests pain medication immediately.
1000: The client is 14 days post motor vehicle collision with complete T4 spinal cord injury. Client is off the unit with PT/OT for evaluation.
1115: Client returned to the room. The client states he feels tired after therapy and requests to be transferred to bed. The client suddenly reports, “I have a pounding headache.” The client rates the headache as 8/10 on the Numerical Rating Scale. He appears irritable and requests pain medication immediately.
1120: Provider is at the bedside and diagnosed the client as experiencing an autonomic dysreflexia emergency. The client states their headache is worsening.
1000: The client is 14 days post motor vehicle collision with complete T4 spinal cord injury. Client is off the unit with PT/OT for evaluation.
1115: Client returned to the room. The client states he feels tired after therapy and requests to be transferred to bed. The client suddenly reports, “I have a pounding headache.” The client rates the headache as 8/10. He appears irritable and requests pain medication immediately.
1120: Provider is at the bedside and diagnosed the client as experiencing an autonomic dysreflexia emergency. The client states their headache is worsening.
1125: Client catheterized with 16Fr catheter. 650 mL of clear yellow urine collected. The client tolerated well. Client positioned into an upright position, removed socks, and fitted sweatpants. The abdomen is soft and nontender. No signs of fecal impaction noted.
1000
The client is 14 days post motor vehicle collision with complete T4 spinal cord injury. Client is off unit with PT/OT for evaluation.
1115
Client returned to room. The client states he feels tired after therapy and requests to be transferred to bed. The client suddenly reports, “I have a pounding headache.” Client rates the headache as 8/10. He appears irritable and requests pain medication immediately.
1120
Provider is at the bedside and diagnosed the client as experiencing an autonomic dysreflexia emergency. The client states their headache is worsening.
1125
Client catheterized with 16Fr catheter. 650 mL of clear yellow urine collected. Client tolerated well. Client positioned into an upright position, removed socks and fitted sweatpants. Abdomen is soft and nontender. No signs of fecal impaction noted.
1330
The client appears calm and resting in bed, showing no signs of acute distress. The client is alert and oriented ×4, with stable baseline findings of motor and sensory loss below the T4 level. The client denies any dizziness or visual disturbances. He reports a mild headache (3/10) with no changes in vision; PERRLA.
Blood pressure is 124/72 mmHg, and heart rate is 68 bpm. Mild 1+ pitting edema is noted bilaterally in the lower extremities, pedal pulses 2+. Clear breath sounds with slight diminishment at the bases, the client denies cough or dyspnea.
Abdomen is soft, nontender, and active bowel sounds. Intermittent catheterization every 6 hours as part of a bladder training regimen, with no signs of retention or distress. The client is tolerating an upright position without adverse symptoms. The client’s skin is warm, dry, and intact, no facial flushing noted.
The nurse is evaluating the client’s response to the treatment plan.
➢ Click to highlight the findings that indicate the client’s condition is improving as expected.
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