Autonomic Dysreflexia: Recognizing the Signs and Taking Action
What are the signs of autonomic dysreflexia in a patient with a T5 complete spinal cord injury?
1. Flushed skin
2. Diaphoresis above the level of injury
3. Elevated blood pressure
4. Severe, pounding headache
5. Bladder distention and bowel impaction
How should a nurse intervene when caring for a patient with autonomic dysreflexia?
The nurse should:
1. Elevate the head of the bed to 90 degrees
2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
Autonomic dysreflexia is a critical condition that can occur in patients with spinal cord injuries, particularly those with upper-level injuries such as T5 complete injuries. It is essential for healthcare providers, especially nurses, to be able to recognize the signs of autonomic dysreflexia and take prompt action to prevent complications.
Recognizing the Signs
Key signs of autonomic dysreflexia include flushed skin, diaphoresis above the level of the injury, elevated blood pressure, and a severe, pounding headache. These symptoms indicate that the patient's body is experiencing a dangerous spike in blood pressure that requires immediate attention.
Taking Action
When caring for a patient with autonomic dysreflexia, the nurse should take the following interventions:
1. Elevate the head of the bed to 90 degrees: This position helps lower blood pressure by facilitating venous return from the extremities.
2. Loosen constrictive clothing: Tight clothing can exacerbate autonomic dysreflexia, so it is important to remove any restrictive garments.
3. Use a fan to reduce diaphoresis: Cooling the patient with a fan can help alleviate sweating and lower body temperature.
4. Assess for bladder distention and bowel impaction: Emptying the bladder and addressing any bowel issues can help resolve triggers for autonomic dysreflexia.
5. Administer antihypertensive medication: Following the healthcare provider's orders, the nurse may need to administer medication to manage the elevated blood pressure and prevent further complications.
These interventions aim to address the symptoms of autonomic dysreflexia promptly and prevent the potentially life-threatening consequences of this condition. It is crucial for nurses to be vigilant in monitoring patients with spinal cord injuries for signs of autonomic dysreflexia to ensure timely and effective treatment.