solving the puzzle of autonomic dysreflexia amy j. olson rn bsn alverno graduate student...

Solving the Puzzle of Autonomic Dysreflexia

Amy J. Olson RN BSNAlverno Graduate [email protected]

Objectives of this Tutorial:• Learner will be able to explain the pathophysiology of autonomic dysreflexia (AD) and the alteration to the generalized stress response.• Learner will identify signs and symptoms of AD.• Learner will be able to list the common causes of AD.

Objectives continued:• Learner will be able to explain how aging, inflammation, and genetics alter the AD presentation and process.• Learner will identify nursing outcomes that are influenced by properly managing and preventing AD.

(Microsoft office clip art, 2007)

Navigation through the Tutorial:

Use this button in the upper right corner to access the menu:

Use this button in the lower right corner to go back a page:

Use this button in the lower right corner to go forward a page:

Click on any underlined words to receive a definition, answer, or to be taken to another slide for more information.

Use this button in the upper left corner to go back to the very last slide you viewed:

(Microsoft Office Clip Art, 2007)

MenuClick on the topic to go directly to that page within the tutorial:

Anatomy

Patho

Signs & Symptoms

Case Study

Causes

Epidemiology

Inflammation

Nursing Interventions

Aging

Genetics

Nursing Outcomes

Altered Stress Response

References

Review of the Anatomy of the Nervous System:

(Porth & Matfin, 2009)


Anatomy of the Peripheral Nervous System (PNS) Click on the question for the answer:


Which system is responsible for

Autonomic Dysreflexia?

The Normal Sympathetic/Parasympathetic Responses:

(Lewis et al, 2000, p. 1591)

Negative feedback loop

What is Autonomic Dysreflexia (AD)?• An amplified sympathetic response from a stimulus (pain, irritant, etc.) that cannot be resolved by the parasympathetic system due to a blockage in the spinal cord from an injury above or at the level of T6.

(Travers, 2009)


Spinal Anatomy Review:

Chart reproduced with permission from the site owner of www.spinalinjury.netImage available at: http://www.spinalinjury.net/html/_spinal_cord_101.html

Click the corresponding arrow on the diagram

where autonomic dysreflexia can occur if

the injury is on or above this level?

Exactly! T6 or above!

No review this slide



Yes T6 and above!

Yes anything T6 and above!

Mr. Z•Mr. Z is your patient today!•He is a 65 year old male who is a C3/C4 vent dependent quadriplegic from a car accident 37 years prior. •He has been in your ICU for the past week due to urosepsis (from Gram negative E-coli).• Is his spinal injury high enough to get Autonomic dysreflexia?

YesRight, T6 and

above!

NoAre you sure? Go back to this

slide!

Mr. Z continued….• By the middle of your shift, Mr. Z’s blood pressure was 158/110 as read from his left arm cuff. You begin to suspect he is experiencing AD. How does AD occur?

Click here to find out!

Pathophysiology of Autonomic Dysreflexia

SympatheticCORRECT!

Para-Sympathetic No! This is

activated later!

(Travers, 2009 )

Click on correct answer:

What part of the PNS will be activated in response to the accumulation of these blocked nerve firings?

Patho of Autonomic Dysreflexia continued:

(Porth & Matfin, 2009, p. 1293).

Microsoft clip art 2007

AD: The Altered Stress Response• In a person with an intact spinal cord: the sympathetic nervous system activates, BP rises, and then the parasympathetic system kicks in and stops the SNS through vasodilation of all vessels.• In Mr. Z, the parasympathetic system is blocked at the injury!


What does this mean?• Above Mr. Z’s injury there will be Parasympathetic activation: Vasodilation • Below the injury you will continue to see Sympathetic activation: Severe constriction of blood vessels which will cause the BP to continue to climb until AD is rectified!


Image reprinted with permission from eMedicine.com, 2011. Available at http://emedicine.medscape.com/article/322809-overview

What will happen to all the blood vessels BELOW Mr. Z’s injury?

Vaso-constriction

Exactly!

Vaso-dilation

No, review the patho

again

Click on the correct answer:

AD at a glance:

Putting AD together:• Stimulus below the injury•Nerve signals from that stimulus are sent• Signals blocked at injury point• Sympathetic nervous system activated - Hypertension• Parasympathetic nervous system is activated but can only reach to the level of injury.

(Porth & Matfin, 2009, p. 1293)

What will happen to Mr. Z’s heart rate?

Click box when you are ready for the answer :

AD’s influence on the • Bradycardia• Significant Atrial Distention:



Mr. Z•Upon closer assessment, you observe Mr. Z’s face is quite flushed and warm to the touch.

• You suspect Mr. Z :

Is probably FebrileNo, reread this

slide

Has significant vasodilation of the vessels leading to

his faceAbsolutely! This is

due to the Parasympathetic

activation

Used with permission from Olson Family Photograph Collection (Olson, 2011)

Signs and Symptoms:• Besides bradycardia, hypertension, and a flushed face; what else might Mr. Z have?

*Click on each sign/symptom for more information*

headache sweating Blotchy skin

Feeling of doom

nasal congestion

Goose bumps

(Porth & Matfin, 2009, pg. 1293)

Cool peripheral extremities

Blurred vision

Pupils constrict

What do you do now?• You have assessed Mr. Z’s signs and symptoms and determined he is dysreflexic. What should you do next?

Place his bed in trendelenberg

position?No! This would further increase

his BP! Mr. Z could stroke!!!

Call the Resident to assess him?

No, while you are calling, Mr.

Z’s BP is climbing!

Place his head of bed up 90

degrees?Absolutely!

Take advantage of a Quad’s orthostatic

hypotension!

Check his bladder for fullness or

place a foley?No, you will do

this but first intervene in his

BP!

1st Nursing interventions for AD:•Head of bed up to 90 degrees in order to take advantage of a quad’s orthostatic hypotension.• Lower the end of the bed (Reverse Trendelenberg) in order to have feet in a dependent position.• Remove or loosen any abdominal binders, ted hose, SCD’s, and foley leg straps.

(Travers, 2009)


Second Step:• After Mr. Z has been completely upright for 2-3 minutes, you retake his BP (151/102). You know his baseline is typically 100’s/60’s.• A good rule of thumb for AD is if your patient’s BP is twice their usual baseline – you would get the MD Stat in order to administer a rapid vasodilator.

(Travers, 2009) (Microsoft Office Clip Art, 2007)

In Mr. Z’s Case:•His BP is elevated (but not dangerously high YET, so you can now work to find the cause).•What is the first place you should look?

Check the linen for a large wrinkle?

No, this has been known to cause AD, but rule out

the #1 cause first!

Check for a developing

pressure sore?No, this has been known to cause AD, but rule out

the #1 cause first!

Check his bladder for distension?

Absolutely! This is the #1 most

occurring cause for AD!!!!


The 3 Common Causes of AD:

(Travers, 2009)

*Rule out each cause by working from the bottom up! Start with the most

common cause first!

Less Common Causes of AD:• Pregnancy/uterine contractions• Procedural/post surgical pain or inflammation (*Anesthesia should be considered for major procedures/surgeries despite altered sensations from the paralysis)• Fractures• Bladder stones• Cystitis

(Louis Calder Memorial Library of the University of Miami/Jackson Memorial Medical Center, 2009)


Urinary Management/Bladder Assessment in AD:

*If the patient does not have an indwelling catheter – insert one (use 2% lidocaine lubricant into the urethra)

*If a catheter is already in place, assess for kinks and patency of the catheter

(if patency is questionable place a new foley).

(Travers, 2009) (Microsoft Clip Art, 2007)

Back to Mr. Z….. • You have assessed Mr. Z’s bladder for distension: he has a 22 Fr. Supra Pubic indwelling foley catheter that you assessed for patency, kinks in the tubing, or a dislodgement of the catheter. His urinary drainage system is patent and intact. Now what should you do?

Turn Mr. Z and assess for a skin

impairment?No, remember to assess from the bottom –

up! Review this slide

Consult chart for last bowel

movement while

hospitalized?Absolutely, a

full bowel is the #2 cause of AD!

Lower head of bed and see if

his BP has normalized?

No! You haven’t found the cause

yet, and this could cause Mr. Z to stroke!!!!!

Mr. Z’s Chart•Upon reviewing Mr. Z’s chart – he has not had his bowel program done for the entire time he has been hospitalized (8 days).• You recheck Mr. Z’s BP (160/109). What is your next step?

Administer Mr. Z’s prn oral

laxative?No, his BP will

continue to climb while the

laxative is absorbed! Mr. Z could have a

stroke!

Call the MD for a stool softener

order?No, his BP will

continue to climb while the stool softener is absorbed! Mr. Z could have a

stroke!

Turn Mr. Z to his side and attempt to

remove any stool present?Yes! This is the only option that will attempt to remove the AD

stimulus!

Bowel Assessment/Management in AD:•Don gloves and use a lubricant (2% lidocaine gel).• Turn patient to their left side and check for stool.•No stool present?

**MONITOR PATIENTS BP DURING THE WHOLE PROCEDURE!

(Agency for Healthcare Research & Quality- U.S. Department of Health & Human Services, 2001)


Mr. Z’s Bowel Assessment:

•Upon examination – you find no stool present in the rectum, but a small amount of brown liquid pours out during assessment.• You stop digital stimulation and recheck Mr. Z’s BP (210/121).


What is the next intervention?• You call Mr. Z’s doctor who promptly orders a medication STAT! Based on the pathophysiology of AD and the quick half-life of the medication needed, what medication should the doctor order?

NifedipineYes! This is available in

sublingual form which allows for quick absorption

MetoprololNo! This is an anti-

hypertensive (Beta-Blocker), but

it is not as fast acting as

sublingual Nifedipine

TimololNo! This is an anti-

hypertensive (Beta-Blocker), but

it is not as fast acting as

sublingual Nifedipine (Microsoft Office Clip Art, 2007)

(Deglin & Vallerand, 1999)

Other Medications used for AD:• Sodium Nitroprusside• Isosorbide dinitrate•Nitroglycerin ointment•Hydralazine•Mecamylamine•Diazoxide• Phenoxybenzamine• Captopril• Prazosin

(Agency for Healthcare Research & Quality – U.S. Department of Health & Human Services, 2001)


Special Considerations:

• If your patient has a stimulus of AD that is not able to be resolved quickly (i.e. surgical incision, pressure sore, bone fracture), he may need a low-dose anti-hypertensive daily for a few weeks.• Anti-hypertensive medication may result in rebound hypotension (esp. orthostatic hypotension).


What happens to Mr. Z?•Due to your AMAZING nursing care, you are able to get Mr. Z a sublingual nifedipine right away - (preventing a stroke, seizure, or even death)!•Mr. Z’s BP decreases from the nifedipine and the surgery team is called. He is found to have an impaction that requires surgery!

(Microsoft Office, Clip Art, 2007)

Epidemiology of AD • 250,000-300,000 Spinal Cord Injured patients in America• 42% are Quadriplegic• 12,000 new spinal injuries per year• 1/3 – 1/2 of all SCI patients are re-admitted to the hospital each year!

Will you take care of a high SCI injury who could have AD?

(National SCI Statistical Center, 2010)

Inflammation’s Role in AD:• Any Pressure Sore below the level of injury could cause AD:


What will happen to these pain

signals?Patho?


AD from a Pressure Sore:

Your patient has a stage III pressure sore what might you

need ordered in order to prevent AD symptoms?

NifedipineNo! This is

short acting. Review this

slide!

Low dose anti-hypertensive

Yes! A pressure sore will take days

to heal!


Aging and AD• SCI Patients are living longer than ever with advances in medical technology.•HIGH risk for Atrial Fibrillation during AD!


(Pine et al, 1991)

Considerations for Elderly AD Candidates:•Give Nifedipine CAUTIOUSLY!• At an increase Rx for developing the top 3 causes of AD:

Why?

Thinner Skin with Age

Decreased Bowel Motility

Decrease in Bladder Size


Genetics & AD• After a spinal injury there is significant growth of Calcitonin Gene-related Peptide-immunoreactive (CGRP+) within the spinal cord. (This growth perpetuates AD)• An exciting study,(Cameron, 2006), was done on rats that involved manipulation of

the genes!

What does this mean for AD in SCI patients in the future?

(Cameron et al, 2006)


The Study?

Nursing Outcomes• Through prompt identification and management of AD, nurses will prevent adverse patient outcomes! Prevention of the following:

Death Stroke Seizure Loss of Vision

Loss of hearing

Heart failure

Kidney failure


Nurses are key in prevention of further loss of functioning!

Educate Educate Educate!• Important Nursing Outcome!Decrease Patient and family Knowledge Deficit Regarding AD! What about AD would you have wanted to teach to Mr. Z and his family?

Signs and

Symptoms of AD!

Absolutely! He has been a quad for a while – but this could save

his life!

Importance of adhering to

Bowel Program!Absolutely! A

full bowel is the #2 cause of AD!

Mr. Z’s risk for developing

Atrial Fibrillation with AD?

Absolutely! He is 65 years old and is at risk!

Click on all the answers that are right!


What is the Necessary Missing Piece of the Puzzle of Autonomic Dysreflexia?

Prompt identification and intervention by ALL Nurses!

Click on the puzzle piece for the answer!

References• Agency for Healthcare Research & Quality - U.S. Department of

Health & Human Services. (Eds.). (2001, July 29). Acute management of autonomic dysreflexia: Individuals with spinal cord injury presenting to health-care facilities. Retrieved February 2, 2011, from AHRQ: Agency for Healthcare Research & Quality Web site: http:/ / www.guideline.gov/ content.aspx?id=2964

• Cameron, A. A., Smith, G. M., Randall, D. C., Brown, D. R., & Rabchevsky, A. G. (2006). Genetic manipulation of intraspinal plasticity after spinal cord injury alters the severity of autonomic dysreflexia. The Journal of Neuroscience, 26(11), 2923-2932.

• Deglin, J. H., & Vallerand, A. H. (1999). Davis's Drug Guide for Nurses (6th ed.). Philadelphia: F.A. Davis Company.

• eMedicine.com. (Ed.). (2009, July 2). AD Image. Retrieved February 1, 2011, from eMedicine.com Web site: http:/ / emedicine.medscape.com/ article/ 322809-overview

• Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2000). Medical Surgical Nursing: Assessment and Management of Clinical Problems (5th ed., Vol. 2). St. Louis, MO: Mosby.

• Lin, V. W., Cardenas, D. D., & Cutter N.C. (2003). Spinal Cord Medicine: Principles & Practice. New York: Medical Publishing.

• Louis Calder Memorial Library of the University of Miami/ Jackson Memorial Medical Center. (2009). Other Complications of Spinal Cord Injury: Autonomic Dysreflexia (Hyperreflexia): Symptoms and Causes. Retrieved January 27, 2011, from Rehab Team Site Web site: http:/ / calder.med.miami.edu/ pointis/ symptoms.html

• National SCI Statistical Center. (2010, February). Spinal cord injury facts and figures at a glance. Retrieved February 15, 2011, from National Spinal Cord Injury Statistical Center Web site: https:/ / www.nscisc.uab.edu/

• Olson A. (2011). Olson Family Picture [Photograph]. Retrieved from Olson Family Photograph Collection. Used with Permission

• Pine, Z. M., Miller, S. D., & Alonso, J. A. (1991). Atrial fibrillation associated with autonomic dysreflexia. American Journal of Physical Medicine & Rehabilitation, 70(5), 271-273.

• Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of Altered Health States (8th ed.). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

• Schuijt, G. B. C., & Menarini, R. P. M. (2007). Bowel dysfunction in spinal cord injury patients: Pathophysiology and management. Pelviperineology: a Multidisciplinary Pelvic Floor Journal, 26(2). Retrieved January 7, 2011, from Pelviperineology Web site: http:/ / www.pelviperineology.org/ practicalbowel-dysfunction_in_spinal_cord_injury.html

• Spinal Cord Injury Information Pages Associates. (2009, March 23). Autonomic Dysreflexia. Retrieved January 29, 2011, from Spinal Cord Injury Information Pages Web site: http:/ / www.sci-info-pages.com/ ad.html

• Travers, P. L. (2009). Autonomic dysreflexia: A clinical rehabilitation problem. Retrieved January 26, 2011, from http:/ / www.neuroanatomy.wisc.edu/ selflearn/ AutonDys.htm

• Weaver, L. C. (2002). What causes autonomic dysreflexia after spinal cord injury? Clinical Autonomic Research, 12(6), 424-426.

• www.spinalinjury.net. (n.d.). Anatomy Chart. Retrieved January 31, 2011, Used with Permission www.spinalinjury.net Web site: http:/ / www.spinalinjury.net/ html/

_spinal_cord_101.html

solving the puzzle of autonomic dysreflexia amy j. olson rn bsn alverno graduate student...

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