POSTACUTE PHASE NURSING: NEUROLOGICAL PROBLEMS-AUTONOMIC DYSREFLEXIA

NEUROLOGICAL SYSTEM

  1. Problems include autonomic dysreflexia (a medical emergency that can lead to cerebral infarction, intracerebral hemorrhage, seizures, myocardial infarction, and even death), pain, paresthesia, hyperesthesia, and sleep disorders (particularly in patients with high quadriplegia)

  2. Causes include:
    • Scar tissue or posttraumatic sympathetic dystrophy
    • Recovery from spinal shock which involves the return of:
      • Some reflexes, which can create an exaggerated response in patients with lesions at T6 and above due to a lack of control from higher centers
      • Sensations, ranging from tingling to severe pain, particularly at the level of the injury, due to the loss of downstream inhibition, realignment of structural and sympathetic connections, release of excitatory pathways, regrowth of neurons in the area of the injury, and the activation of secondary nociceptive pathways
    • Noxious stimuli below the level of injury, which can trigger autonomic dysreflexia, such as distended bladder, constipation or fecal impaction, pressure sores, etc.
    • Hypoxia, which can cause serious nocturnal hypoxic episodes, and respiratory muscle paralysis or weakness, which can cause sleep-induced respiratory problems.

  3. Nursing Diagnoses include hypothermia, knowledge and self-care deficits, impaired physical mobility and swallowing, sensory/perceptual alterations, sexual dysfunction, sleep pattern disturbance, risk of injury, pain, and autonomic dysreflexia, which presents with:
    • Headache (may be pounding or severe)
    • Paroxysmal hypertension (blood pressure 20 mm Hg above baseline, which is frequently lower than normal in SCI patients) and flushing of face and neck
    • Bradycardia
    • Profuse sweating above the level of injury
    • Piloerection (goose flesh) below the level of injury
    • Chills without fever, basal congestion, and bronchospasm
    • Blurred or tunnel vision and anxiety/apprehension

  4. Assessments include assessing baseline and monitoring highest sensory level, motor function, and reflexes; monitoring vital signs and complaints of pain or abnormal sensations; MRI or CT scans and x-rays of spine; and monitoring for signs and symptoms of autonomic dysreflexia

  5. Nursing Interventions include:
    • Providing for total care needs of patient
    • Providing information to patient and family
    • Treating autonomic dysreflexia:
      • Elevate the head immediately to a 90 degree angle and place the legs in a dependent position, if possible, to lower the blood pressure
      • Loosen constrictive clothing, antiembolic hose, abdominal binders, etc.
      • Remove noxious stimuli, such as a distended bladder, constipation or fecal impaction, urinary calculi, cystitis, acute abdominal lesions, operative incisions, uterine labor contractions, pressure on the glans penis, and stimulation from skin lesions
        • Check and irrigate catheter immediately, or replace, if obstructed
        • Catheterize patients on intermittent catheterization immediately
        • Anesthetize with a topical ointment and then disimpact the lower bowel, if stool is present
        • Anesthetize with a topical spray, if pressure ulcer is the noxious stimulus
        • See also the clinical practice guidelines for Autonomic Dysreflexia from the Consortium for Spinal Cord Medicine
      • Monitor blood pressure every 2-3 minutes and vital signs every 5 minutes
      • Administer drugs to lower the blood pressure, if necessary
    • Evaluating pain and pain control via drugs, imagery, biofeedback, relaxation techniques, and surgery, such as dorsal column stimulation or surgical ablation of the dorsal root of the spinal cord
    • Beginning patient/family teaching to prevent autonomic dysreflexia and injury to tissue, and using comfort measures

The PoinTIS Spinal Cord Nursing site of the SCI Manual for Providers is based on information in Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing, 4th ed., Philadelphia: Lippincott, 1997; Chin PA, et al. Rehabilitation Nursing Practice, N.Y.: McGraw-Hill, 1998; and Wirtz KM, Managing chronic spinal cord injury: issues in critical care, Critical Care Nurse 1996 16(4):24-35 Aug., except for information where other papers are cited.