Risk for Autonomic Dysreflexia | Nursing Care Plan for Spinal Cord Injury

Risk factors may include
Altered nerve function (spinal cord injury at T8 and above)
Bladder, bowel, skin stimulation—tactile, pain, thermal

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Symptom Control
Recognize signs and symptoms of syndrome.
Identify preventive and corrective measures.
Neurological Status: Autonomic
Experience no episodes of dysreflexia.

Nursing intervention with rationale:
1. Identify and monitor precipitating or risk factors, such as bladder or bowel distention or manipulation; bladder spasms, stones, and infection; skin or tissue-pressure areas and prolonged sitting position; and temperature extremes or drafts.
Rationale: Visceral distention is the most common cause of AD, which is considered an emergency. Treatment of acute episode must be carried out immediately by removing stimulus or treating unresolved symptoms, then interventions must be geared toward prevention.

2. Observe for signs and symptoms of syndrome—changes in blood pressure, paroxysmal hypertension, tachycardia or bradycardia, autonomic responses, such as sweating, flushing above level of lesion, pallor below injury, chills, goose flesh, piloerection, nasal stuffiness, and severe pounding headache, especially in occiput and frontal regions. Note associated symptoms, such as chest pains, blurred vision, nausea, metallic taste, Horner’s syndrome—contraction of pupil, partial ptosis of eyelid, and sometimes loss of sweating over one side of the face.
Rationale: Early detection and immediate intervention is essential to prevent serious consequences or complications. Note: Average systolic BP in tetraplegic client—after spinal shock has resolved—is 120 mm Hg; therefore, readings greater than 140 mm Hg are considered elevated.

3. Stay with client during episode.
Rationale: This is a potentially fatal complication. Continuous monitoring and intervention may reduce client’s level of anxiety.

4. Monitor BP frequently (every 3 to 5 minutes) during acute AD. Take action to eliminate stimulus. Continue to monitor BP at intervals after symptoms subside.
Rationale: Aggressive therapy and removal of stimulus may drop BP rapidly, resulting in a hypotensive crisis, especially in those clients who routinely have low BP. In addition, AD may recur, particularly if stimulus is not eliminated.

5. Elevate head of bed to 45-degree angle or place client in sitting position.
Rationale: Elevation of the head of bed lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing the tetraplegic client in sitting position automatically lowers BP.

6. Correct or eliminate causative stimulus as able, such as bladder, bowel, and skin pressure, including loosening tight leg bands or clothing; removing abdominal binder and elastic stockings; and temperature extremes.
Rationale: Removing noxious stimulus usually terminates episode and may prevent more serious AD; for example, in the presence of sunburn, topical anesthetic should be applied. Removal of constrictive clothing or restrictive devices also promotes venous pooling to help lower BP. Note: Removal of bowel impaction must be delayed until cardiovascular condition is stabilized.

7. Inform client and SO of warning signals and how to prevent or limit onset of syndrome.
Rationale: This lifelong problem can be largely controlled by avoiding pressure from overdistention of visceral organs or pressure on the skin.

8. Administer medications, as indicated (intravenous [IV], parenteral, oral, or transdermal) and monitor response: Diazoxide (Hyperstat) and hydralazine (Apresoline)
Rationale: These medications reduce BP if severe or sustained hypertension occurs.

9. Nifedipine (Procardia) and 2% nitroglycerin ointment (Nitrostat)
Rationale: Sublingual administration usually effective in absence of IV access for diazoxide (Hyperstat), but may require repeat dose in 30 to 60 minutes. These drugs may be used in conjunction with topical nitroglycerin.

10. Morphine sulfate
Rationale: Morphine sulfate relaxes smooth muscle to aid in lowering BP and muscle tension.