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Autonomic Dysreflexia: Nursing Care
- 1. Autonomic Dysreflexia A guide to acute nursing care prevention, and education
- 3. Know how to manage acute AD crisis
- 4. Know some ways to prevent AD
- 5. Effectively educate patients on the management and prevention of AD
- 7. What is AD? Patients most at risk of AD are those with SCI above T6 who have passed through the acute stage of spinal cord injury (spinal shock). This is a medical emergency and must be treated with prompt action. High blood pressure can lead to heart arrhythmias and stroke. Repeated episodes of AD can cause long term organ and vascular damage.
- 12. Causes #1 cause is a full bladder #2 cause is a full bowel
- 14. gastric ulcers, gallstones, other GI disturbances
- 15. tight clothing, leg braces, shoes
- 16. patient lying or sitting on hard object
- 17. pressure ulcer
- 18. ingrown toenail
- 19. insect bites and other minor injuries
- 20. DVT
- 22. menstruation
- 23. pregnancy
- 26. rapid changes in temperature
- 27. positioning problem, lack of circulation to limb
- 28. drug stimulants
- 30. Bradycardia
- 31. Cardiac arrhythmias, A-fib, PVC, AV conduction abnormalities
- 33. Piloerection
- 34. Flusing of skin, especially face, neck, shoulders
- 36. blurred vision
- 37. spots in visual fields
- 38. nasal congestion
- 39. anxiety, sense of impending doom * slient AD does not have symptoms despite signficant elevation in BP
- 40. Acute Care Nursing Plan Goals Locate and remove stimuli Lower blood pressure Administer prescribed meds Notify doctor
- 41. Step-by-Step Care 1. Sit the patient up This will help to reduce the blood pressure to the head and upper body. Patient must remain sitting up with head of bed elevated to 90 degrees until crisis has passed
- 42. Step-by-Step Care 2. Loosen restrictive clothing This will allow pooling of blood in lower extremities to reduce blood pressure. It may also be the source of the crisis. Remove shoes, loosen braces, remove elastic anti-embolism stockings, and inspect for any other sources of pain related to clothing or devices.
- 43. Step-by-Step Care 3. Closely monitor BP Attach intermittent BP device and check BP every 5 minutes or more as needed. This will allow you to identify whether or not you have identified the problem. For example, if you cath the patient and that results in an immediate drop in BP then the source has been identified, Otherwise continue to investigate the cause of the crisis. If you have a cardiac patient, apply 6 lead EKG at this time. Some protocols indicate that a systolic BP above 150Hgmm requires pharmaceutical intervention.
- 44. Step-by-Step Care 4. Check the Bladder If the patient has a foley catheter, check for any kinks or obstructions in the tubing. If foley is not draining replace it. Call a doctor if there is any difficulty replacing the foley. Cath the patient to empty the bladder. Apply lidocaine jelly to the urethra 2 minutes prior to cathing to avoid further painful stimuli. If there is a doubt about the bladder being empty, use a bladder scanner. Observe patient's urine. An odor or discoloration may point to bladder infection or kidney problems. Collect sample for analysis.
- 45. Step-by-Step Care 5. Check the bowels Impacted bowels can often lead to a crisis. Apply lidocaine 2 minutes prior to digital deimpactation. While the patient is in the lateral position, check patient's sacral area and buttocks for pressure ulcers or other causes of pain. Inspect area under patient to make sure they were not lying on any object such as an IV cap. A digical rectal exam may exacerbate the crisis! If blood pressure rises during the examination, stop, instill more lidocaine, and call the doctor.
- 46. Step-by-Step Care 6. Check for other noxious stimuli on their body, toes up.
- 47. Step-by-Step Care Check for any other sources of pain. Start at the feet and work up. Inspect for ingrown toenails, bites, scratches or other minor wounds. Check for pressure ulcers under the heels. Make sure socks and pants are not tight. Loosen leg braces and pants. Make sure the leg openings of underwear are not constricting the upper thighs. Check to see if female patient has vaginal bleeding or discharge. Check male patients to see if they are lying on the scrotum. Check for discharge or swelling. Make sure patient is not too hot or too cold. Check temperature to detect a possible infection
- 48. “The Five B's” B ed Up B P B ladder B owels B ody
- 51. Home Health: consider admitting
- 52. Teach patient: call 911 or go to ED
- 55. Inspect patient bed often for foreign objects
- 56. Check records for past crisis and causes
- 57. Avoid tight fitting clothes, changes in temp.
- 59. positioning
- 60. vein/artery access procedures Continuously monitor BP for signs of AD!
- 61. Surgery/ Outpatient Testing Several situations a patient faces during surgery or outpatient procedures puts them at risk for AD. - Hypothermia: Use warming blankets to prevent hypothermia Use warmed IV fluids if ordered. - Positioning: Even if the patient does not feel awkward positioning, their ANS may detect muscle stretching and awkward positions that restrict circulation. - Procedures that puncture and cause pain below the SCI such as an angiogram may cause ADS.
- 63. cath/bowel care
- 64. educate family
- 65. card with plan of care
- 66. medical bracelet
- 67. References Paralyzed Veterans of America/Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities. Washington (DC): Paralyzed Veterans of America (PVA); 2001 Jul. 29 p. Denise I Campagnolo, MD, MS, Autonomic Dysreflexia in Spinal Cord Injury: Treatment & Medication , Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers, 2009 Glynis Collis Pellat, Spinal Surgery for Acute Traumatic Spinal Cord Injury: Implications for Nursing , British Journal of Neuroscience Nursing, Aug/Sept 2010, Vol 6, Number 6, PP 271-275 Autonomic Dysreflexia: What You Should Know , Consortium for Spinal Cord Management. www.pva.org
Hinweis der Redaktion
- Patients most at risk of AD are those with SCI above T6 who have passed through the acute stage of spinal cord injury (spinal shock). This is a medical emergency and must be treated with prompt action. High blood pressure can lead to heart arrythmias and stroke. Repeated episodes of AD can cause long term organ and vascular damage.
- this will help to reduce the blood pressure to the head and upper body. Patient must remain sitting up with head of bed elevated to 90 degrees until crisis has passed
- This will allow pooling of blood in lower extremities to reduce blood pressure. It may also be the source of the crisis. Remove shoes, loosen braces, remove elastic anti-embolism stockings, and inspect for any other sources of pain related to clothing or devices.
- Attach intermittent BP device and check BP every 5 minutes or more as needed. This will allow you to identify whether or not you have identified the problem. Example, if you cath the patient and that results in an immediate drop in BP then the source has been identified, Otherwise continue to investigate the cause of the crisis. If you have a cardiac patient, apply 6 lead EKG at this time. Some protocols indicate that a systolic BP above 150Hgmm requires pharmaceutical intervention.
- If the patient has a foley catheter, check for any kinks or obstructions in the tubing. If foley is not draining replace it. Call a doctor if there is any difficulty replacing the foley. If the patient does intermittent cathing, cath the patient to empty the bladder. Apply lidocaine jelly to the urethra 2 minutes prior to cathing to avoid further painful stimuli. If there is a doubt about the bladder being empty, use a bladder scanner. Observe patient's urine. An odor or discoloration may point to bladder infection or kidney problems. Collect sample for analysis.
- Impacted bowels can often lead to a crisis. Apply lidocaine 2 minutes prior to digital deimpactation. While the patient is in the lateral position, check patient's sacral area and buttocks for pressure ulcers or other causes of pain. Inspect area under patient to make sure they were not lying on any object such as an IV cap. A digical rectal exam may exacerbate the crisis! If blood pressure rises during the examination, stop, instill more lidocaine, and call the doctor.
- Check for any other sources of pain. Start at the feet and work up. Inspect for ingrown toenails, bites, scratches or other minor wounds. Check for pressure ulcers under the heels. Make sure socks and pants are not tight. Loosen leg braces and pants. Make sure the leg openings of underwear are not constricting the upper thighs. Check to see if female patient has vaginal bleeding or discharge. Check male patients to see if they are lying on the scrotum. Check for discharge or swelling. Make sure patient is not too hot or too cold. Check temperature to detect a possible infection
- Several situations a patient faces during surgery or outpatient procedures puts them at risk for AD. - Hypothermia: Use warming blankets to prevent hypothermia Use warmed IV fluids. - Positioning: Even if the patient does not feel awkward positioning, their ANS may detect muscle stretching and awkward positions that restrict circulation. - Procedures that puncture and cause pain below the SCI such as an angiogram may cause ADS.
- The spinal cord patient must be educated on how to stop an AD crisis, and how to guide family and caregivers. They should have an AD kit prepared that has a cath set, lidocaine, prescribed medications, and step by step instructions. If the person or caregivers are not able to perform a cath procedure, the patient should call 911.