一位 T6 以上脊髓損傷病人，突發頭痛、出汗與高血壓。護理師的首要行動為何？
A nurse is caring for a client with a spinal cord injury at T6 level. The client develops sudden headache, diaphoresis, and hypertension. What is the nurse's priority?
- ACheck for bladder distention✓ 正解檢查是否有膀胱脹滿
- BAssess for DVT評估是否有深部靜脈血栓形成
- CChange the client's position改變病人姿勢
- DAdminister antihypertensive medication給予抗高血壓藥物
此個案呈現典型的自主神經反射異常（Autonomic Dysreflexia），常見於 T6 以上脊髓損傷的病人。這是由於損傷平面以下的刺激（如膀胱脹滿、便秘）引發交感神經反射性過度興奮，導致血管收縮、嚴重高血壓、頭痛與出汗。這是醫療急症，若不處理可能導致腦出血。處理首要原則是「消除刺激源」，在臨床上，膀胱脹滿是最常見的誘因，因此應優先檢查並排空膀胱，同時將病人擺位成坐姿以降低血壓。
This presentation is classic autonomic dysreflexia, common in spinal cord injuries at T6 or above. A noxious stimulus below the level of injury (often bladder distention or constipation) triggers an exaggerated sympathetic response causing severe hypertension, headache, and diaphoresis. It is a medical emergency that can cause stroke if untreated. The priority is to remove the trigger; since bladder distention is the most common cause, the nurse should check and relieve it first while sitting the client upright to lower blood pressure.
台美臨床處理自主神經反射異常的標準流程高度一致，皆強調「坐起、排空膀胱、檢查腸道」的處理順序。