NX is caring for pt with complete T5 spinal cord injury, notes flushed skin, diaphoresis above T5, and BP 162/96 pt reports severe pounding headache, what would the NX do?
- Elevating the HOB to 90 degrees (High Fowlers)
- Loosen constrictive clothing
- Administer anti-hypertensive medication
- Assess for bladder distention and fecal impaction