Autonomic Dysreflexia (AD) is a potentially life-threatening medical emergency that occurs in individuals with spinal cord injuries at or above the T6 level. This condition requires immediate recognition and intervention to prevent severe complications such as stroke, seizures, or death.
Causes (Related to)
Autonomic Dysreflexia can be triggered by various factors, with several conditions contributing to its onset:
- Spinal cord injury at or above T6 level
- Noxious stimuli below the level of injury including:
- Bladder distention
- Bowel impaction
- Pressure ulcers
- Tight clothing
- Ingrown toenails
- Medical procedures such as:
- Catheterization
- Digital stimulation
- Surgical procedures
- Environmental factors include:
- Temperature extremes
- Positioning issues
- Pressure points
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Severe headache
- Blurred vision
- Nasal congestion
- Anxiety or apprehension
- Tingling sensation
- Metallic taste in the mouth
Objective: (Nurse assesses)
- Sudden increase in blood pressure (>20-40 mmHg above baseline)
- Bradycardia or tachycardia
- Profuse sweating above injury level
- Flushing of skin above injury level
- Pale, cold skin below injury level
- Pilomotor reflex (goosebumps)
- Dilated pupils
Expected Outcomes
- The patient’s blood pressure will return to baseline within 15 minutes
- The patient will remain free from complications
- The patient will identify and avoid triggers
- The patient and caregivers will demonstrate knowledge of prevention strategies.
- The patient will maintain a bowel and bladder program to prevent episodes
Nursing Assessment
Monitor Vital Signs
- Check blood pressure every 2-5 minutes during an episode
- Monitor heart rate and rhythm
- Assess respiratory status
- Document baseline vital signs
Identify Triggering Factors
- Assess for bladder distention
- Check for bowel impaction
- Evaluate skin for pressure areas
- Inspect for tight clothing or positioning issues
Evaluate Neurological Status
- Monitor level of consciousness
- Assess pupillary response
- Check for seizure activity
- Document symptoms progression
Review Prevention Measures
- Assess compliance with bowel/bladder program
- Evaluate skincare routine
- Check positioning schedule
- Review medication regimen
Document Episode Details
- Record trigger factors
- Note intervention effectiveness
- Track time to resolution
- Document complications
Nursing Care Plans
Nursing Care Plan 1: Ineffective Tissue Perfusion
Nursing Diagnosis Statement:
Ineffective Tissue Perfusion related to autonomic nervous system dysfunction as evidenced by severe hypertension and altered skin characteristics above and below level of injury.
Related Factors:
- Autonomic nervous system imbalance
- Spinal cord injury
- Vasoconstriction below the injury level
- Vasodilation above injury level
Nursing Interventions and Rationales:
- Elevate the head of the bed immediately
Rationale: Promotes blood pooling and reduces blood pressure - Remove or loosen tight clothing
Rationale: Eliminates potential triggers and promotes circulation - Monitor vital signs every 2-5 minutes
Rationale: Tracks response to interventions
Desired Outcomes:
- Blood pressure will return to baseline
- Patient will maintain adequate tissue perfusion
- Signs and symptoms will resolve within 15 minutes
Nursing Care Plan 2: Risk for Autonomic Dysreflexia
Nursing Diagnosis Statement:
Risk for Autonomic Dysreflexia related to spinal cord injury above T6 as evidenced by history of AD episodes.
Related Factors:
- Level of spinal cord injury
- History of previous episodes
- Presence of known triggers
- Knowledge deficit
Nursing Interventions and Rationales:
- Implement regular bladder emptying schedule
Rationale: Prevents bladder distention - Maintain bowel program
Rationale: Prevents constipation and bowel impaction - Conduct regular skin assessments
Rationale: Identifies potential pressure injuries early
Desired Outcomes:
- Patient will remain free from AD episodes
- Patient will identify early warning signs
- Patient will maintain preventive measures
Nursing Care Plan 3: Deficient Knowledge
Nursing Diagnosis Statement:
Deficient Knowledge related to complexity of condition as evidenced by verbalization of questions about AD management.
Related Factors:
- Lack of exposure to information
- Misinterpretation of information
- Complexity of management
- Language barriers
Nursing Interventions and Rationales:
- Provide education about triggers
Rationale: Enables prevention of episodes - Teach emergency management steps
Rationale: Ensures prompt intervention - Demonstrate proper positioning techniques
Rationale: Prevents pressure-related triggers
Desired Outcomes:
- Patient will verbalize understanding of AD
- Patient will demonstrate proper management techniques
- Caregivers will identify warning signs
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to fear of AD episode as evidenced by expressed concerns and increased tension.
Related Factors:
- Unpredictability of episodes
- Previous traumatic experiences
- Lack of control
- Health uncertainty
Nursing Interventions and Rationales:
- Validate patient concerns
Rationale: Provides emotional support - Teach relaxation techniques
Rationale: Reduces anxiety levels - Develop coping strategies
Rationale: Improves sense of control
Desired Outcomes:
- Patient will report decreased anxiety
- Patient will use effective coping strategies
- Patient will maintain emotional well-being
Nursing Care Plan 5: Risk for Injury
Nursing Diagnosis Statement:
Risk for Injury related to complications of autonomic dysreflexia as evidenced by potential for stroke or seizures.
Related Factors:
- Severe hypertension
- Altered consciousness
- Seizure activity
- Cardiovascular complications
Nursing Interventions and Rationales:
- Maintain safe environment
Rationale: Prevents injury during episodes - Monitor neurological status
Rationale: Identifies complications early - Keep emergency medications accessible
Rationale: Ensures prompt treatment
Desired Outcomes:
- Patient will remain free from injury
- Patient will maintain safety during episodes
- Complications will be prevented
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Ebrahimi H, Maroufi SF, Abdollahzadegan S, Rahimi-Movaghar V. Clinical Practice Guideline Development for Autonomic Dysreflexia in Spinal Cord Injury. Med J Islam Repub Iran. 2023 Oct 9;37:109. doi: 10.47176/mjiri.37.109. PMID: 38145189; PMCID: PMC10744198.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009 Apr;90(4):682-95. doi: 10.1016/j.apmr.2008.10.017. PMID: 19345787; PMCID: PMC3108991.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Solinsky R, Svircev JN, James JJ, Burns SP, Bunnell AE. A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries. J Spinal Cord Med. 2016 Nov;39(6):713-719. doi: 10.1080/10790268.2015.1118186. Epub 2015 Dec 14. PMID: 26838482; PMCID: PMC5137561.
