Autonomic dysreflexia (AD) is a medical condition that involves the overreaction of the autonomic nervous system (ANS) to stimulation usually due to spinal cord injury.
AD may result from spinal injuries that involve the area from the shoulder blades or above. The body parts below the damaged spinal injuries may feel numb, and the patient is rendered unable to control the muscles in these areas.
However, the nerves still attempt to send signals back to the brain, causing an abnormal reaction (dysreflexia or hyperreflexia) to stimuli.
Causes and Risk Factors of Autonomic Dysreflexia
- Overfull bladder or bladder distention
- Urinary tract infections (UTIs)
- Overfull bowel or bowel distention
- Constipation
- Gastrointestinal disorders such as gastritis, stomach ulcers, and gallstones
- Sexual activity
- Trauma – broken bones or other injuries
- Extreme temperatures or sudden changes in temperature
- Tight clothing or devices
- Ingrown toenails
Signs and Symptoms of Autonomic Dysreflexia
- Pounding headache
- Feeling flushed
- Bradycardia – slow heart rate
- High blood pressure
- Trouble breathing
- Heavy sweating
- Dilated pupils
- Blurry vision
- Blotching above the level of injury
- Goosebumps below the level of injury
- Nasal congestion
Expected Outcomes & Goals for Autonomic Dysreflexia
Goal: Prevent AD triggers and minimize the risk of episodes. Outcome: The patient will remain free from AD episodes by avoiding triggers and implementing preventive measures, such as regular bowel and bladder management, skin integrity maintenance, and proper positioning.
Goal: Early recognition and prompt intervention during an AD episode. Outcome: The nurse will identify the signs and symptoms of AD promptly, initiate appropriate interventions, and notify the healthcare team to prevent complications and provide timely treatment.
Goal: Maintain hemodynamic stability during an AD episode. Outcome: The nurse will monitor vital signs frequently, assess for signs of hypertension (elevated blood pressure) or hypotension (low blood pressure), and take appropriate measures to stabilize blood pressure within safe ranges.
Goal: Relieve the triggering stimulus and alleviate symptoms. Outcome: The nurse will identify and remove the causative factor that triggered the AD episode, such as bladder distension or tight clothing. Additionally, interventions to alleviate symptoms, such as elevating the head of the bed and loosening restrictive clothing, will be implemented.
Goal: Educate the patient and caregivers about AD prevention and management. Outcome: The nurse will provide education on AD triggers, signs, symptoms, and preventive measures to the patient and caregivers. This education will empower them to recognize and respond appropriately to AD episodes, minimizing the risk of complications.
Nursing Assessment and Rationales
Assess vital signs Rationale: AD can cause significant changes in blood pressure, so monitoring vital signs is essential to detect hypertension (elevated blood pressure) or hypotension (low blood pressure), which are common symptoms of AD.
Evaluate for triggers Rationale: AD is usually triggered by specific stimuli below the level of injury, such as a distended bladder, urinary tract infection, constipation, pressure ulcers, tight clothing, or any other noxious stimulus. Identifying and removing the trigger is crucial for managing AD effectively.
Assess for signs and symptoms of AD Rationale: Early recognition of AD is vital for prompt intervention. Assess for symptoms such as severe headache, profuse sweating above the level of injury, flushing or pallor, nasal congestion, piloerection (goosebumps), bradycardia (slow heart rate), and respiratory distress.
Check bladder and bowel status Rationale: Bladder or bowel distension is a common trigger for AD. Assess for bladder fullness, urinary retention, or catheter obstruction. Evaluate bowel function for constipation or impaction, as these can contribute to AD episodes.
Assess skin integrity Rationale: Skin breakdown, pressure ulcers, or any other source of irritation can trigger AD. Evaluate the skin for redness, breakdown, or any areas of pressure. Pay close attention to bony prominences and areas under medical devices (e.g., braces, splints) that may cause friction.
Evaluate neurological status Rationale: Assess the patient’s neurological status, including sensory and motor function, to establish a baseline and detect any changes that may indicate worsening AD or associated complications.
Obtain a thorough medical history Rationale: Understanding the patient’s medical history, including the level and extent of the spinal cord injury, previous episodes of AD, and known triggers, helps in developing an individualized care plan and preventing future episodes.
Involve the patient and caregiver Rationale: Engage the patient and caregiver in the assessment process to gather additional information about potential triggers and symptoms. Their involvement is crucial for effective AD management and prevention.
Nursing Interventions and Rationales for Autonomic Dysreflexia
Elevate the head of the bed to a sitting position: Rationale: Elevating the head of the bed to 45 degrees or sitting the patient upright helps to reduce blood pressure by promoting venous pooling in the lower extremities, which can help alleviate the hypertension associated with AD.
Loosen constrictive clothing or remove any tight objects: Rationale: Tight clothing or constrictive objects can exacerbate AD by further stimulating the autonomic nervous system. Removing or loosening such items helps to reduce the triggering stimulus and alleviate symptoms.
Assess and address bladder distension: Rationale: A distended bladder is a common trigger for AD. Assess for urinary retention or obstruction and initiate measures to relieve bladder distension, such as catheterization or manual expression, as appropriate.
Check for bowel impaction or constipation: Rationale: Bowel impaction or constipation can contribute to AD episodes. Evaluate the patient for signs of constipation or impaction and implement interventions to promote regular bowel movements, such as administering stool softeners, providing adequate hydration, and encouraging fiber intake.
Evaluate for skin irritation or pressure ulcers: Rationale: Skin breakdown or pressure ulcers can trigger AD. Assess the skin for any signs of redness, breakdown, or areas of pressure. Relieve pressure by repositioning the patient regularly and provide appropriate wound care as needed.
Administer antihypertensive medication as prescribed: Rationale: In severe cases of AD with persistent hypertension, healthcare providers may prescribe antihypertensive medications to help lower blood pressure. Administer the medication as ordered, closely monitoring the patient’s response and vital signs.
More Nursing Diagnoses for Autonomic Dysreflexia
- Risk for Seizure related to loss of muscular control secondary to autonomic dysreflexia
- Deficient Knowledge related to autonomic dysreflexia as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
- Risk for Fall related to loss of sensory coordination and muscular control secondary to autonomic dysreflexia
- Risk for infection related to catheterization
Nursing Test Questions for Autonomic Dysreflexia
Question 1: A nurse is caring for a patient with a spinal cord injury at the T5 level. Which of the following stimuli below the level of injury is most likely to trigger autonomic dysreflexia (AD)?
A. Urinary tract infection
B. Gastric ulcer
C. Migraine headache
D. Sinusitis
Answer: A. Urinary tract infection Rationale: AD is commonly triggered by noxious stimuli below the level of injury, such as bladder distension, urinary tract infection, or urinary retention. In this case, a urinary tract infection is the most likely trigger for AD.
Question 2: A patient with a spinal cord injury at the T4 level suddenly develops severe hypertension, pounding headache, and profuse sweating above the level of injury. Which nursing intervention should the nurse prioritize?
A. Administer a nonsteroidal anti-inflammatory drug (NSAID).
B. Assess the patient’s bladder for distension or urinary retention.
C. Position the patient in a flat, supine position.
D. Provide emotional support to the patient.
Answer: B. Assess the patient’s bladder for distension or urinary retention. Rationale: The patient’s symptoms are consistent with autonomic dysreflexia (AD), and the most common trigger for AD in patients with spinal cord injury is bladder distension or urinary retention. Assessing the bladder and relieving the distension or obstruction should be the nurse’s priority.
Question 3: A nurse is caring for a patient with autonomic dysreflexia (AD). Which of the following actions should the nurse take first?
A. Administer an antihypertensive medication.
B. Elevate the head of the bed to a sitting position.
C. Notify the healthcare provider.
D. Loosen any constrictive clothing.
Answer: B. Elevate the head of the bed to a sitting position. Rationale: In a patient experiencing AD, elevating the head of the bed to a sitting position (45 degrees) helps to reduce blood pressure by promoting venous pooling in the lower extremities. This action should be taken first to alleviate hypertension associated with AD.
Question 4: A patient with a spinal cord injury is experiencing autonomic dysreflexia (AD). Which of the following signs should the nurse expect to find during an AD episode?
A. Bradycardia and hypotension
B. Hypothermia and tachycardia
C. Hypertension and piloerection
D. Hypoglycemia and bradypnea
Answer: C. Hypertension and piloerection Rationale: Hypertension (elevated blood pressure) is a hallmark sign of autonomic dysreflexia (AD). Piloerection (goosebumps) may also be present due to the intense sympathetic nervous system response. Bradycardia and hypotension are not typical findings in AD.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
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The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care
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