14. Autonomic dysreflexia (autonomic hyperreflexia): a group of symptoms in which many spinal cord autonomic responses are activated simultaneously. This may occur when cord lesions are above the sixth thoracic vertebra; it is most commonly seen with cervical and high thoracic cord injuries; may occur up to 6 yr after injury.
    1. Pathophysiology: pathological reflex condition, which is an acute medical emergency characterized by extreme hypertension and exaggerated autonomic responses to stimuli.
    2. Risk factors:
       1. Distention of bladder or rectum.
       2. Stimulation of skin, , decubitus ulcers, wrinkled clothing.
       3. Stimulation of pain receptors.
    3. Assessment:
       1. Subjective data:
          1. Severe, pounding headache.
          2. Blurred vision; sees spots in front of eyes.
          3. Nausea.
          4. Restlessness.
          5. Feels flushes.
       2. Objective data:
          1. Severe hypertension (systolic BP may reach 300 mm Hg).
          2. Bradycardia (30-40/min); fever.
          3. Profiise diaphoresis, above level of injury, Flushing of skin above level of injury.
          4. Pale skin below level of injury.
          5. Pilomotor spasm (goose flesh); chills.
          6. Nasal congestion.
          7. Distended bladder, bowel.
          8. Skin breakdown.
          9. Seizures.
    4. Analysis/nursing diagnosis:
       1. Dysreflexia related to high spinal cord injury.
       2. Risk for injury related to complications of hypertension, CVA.
       3. Visual sensory/perceptual alteration related to blurred vision.
       4. Urinary retention related to inability to empty bladder due to spinal injury.
       5. Constipation related to inability to establish successful bowel training program.
       6. Impaired skin integrity related to immobility.
    5. Nursing plan/implementation:
       1. Goal: decrease symptoms to prevent serious side effects.
          1. Elevate head of bed; this lowers BP in persons with high spinal cord injuries.
          2. Identify and correct source of stimulation if possible; notify physician.
          3. Monitor vital signs (BP) ql5min and pm; uncontrolled hypertension can lead to stroke, blindness, death.
          4. Give medications as ordered: nitrates, nifedipine (Procardia), or hydralazine (Apresoline).
       2. Goal: maintain patency of catheter.
          1. Monitor output; palpate for distended bladder.
          2. Check for tubing kinks; irrigate catheter prn.
          3. Insert new catheter immediately if blocked. Do not Credè or tap the bladder; it could exacerbate the response.
          4. Culture if infection suspected.
       3. Goal: promote regular bowel elimination.
          1. Bowel training program.
          2. Administer suppository/enemas/laxatives as ordered and prn.
          3. When checking for and removing impaction, first use anesthetic ointment (, dibucaine [Nupercainai] ointment) to decrease irritation.
       4. Goal: prevent decubitus ulcers.
          1. Meticulous skin care.
          2. Position change ql-2.
          3. Flotation pads, alternating pressure mattress on bed and wheelchair.
       5. Goal: health teaching.
          1. How to recognize risk factors that could initiate this condition.
          2. Methods to prevent situations that increase risk, , bowel program, bladder program, skin care, position change schedul
    6. Evaluation/outcome criteria:
    1. BP remains wihin normal limits.
    2. No complications occur