The patient has a complete T5 spinal cord injury (this is a distractor, ignore it).
Assessment: flushed skin, diaphoresis above T5, BP 162/96. Severe pounding headache
Is it OK to elevate HOB 90 degrees?
Fan to reduce diaphoresis?
Yes, it's necessary to elevate HOB to 90 degrees and place extremeties in dependent position to decrease venous return to the heart and increase venous return to the brain. HIGH BP is the most life-threatening condition
NO! No fan because cold drafts may trigger Autonomic Dysreflexia
Also, this is s/s of autonomic dysreflexia therefore remove tactile stimuli (remove constrictive clothing, assess for bowel impaction and bladder distention). Correct any problems. Give antihypertensive meds b/c elevated BP is the most life-threatening complication!!!