Autonomic Dysreflexia Hyperreflexia Nursing Review: Symptoms, Treatment

hey everyone at CR thread stoners sorry and calm and today we're going to talk about autonomic dysreflexia and after you get done watching this YouTube video don't forget to access the free quiz that will test you on this condition so let's get started what is autonomic dysreflexia also refer to as ad or autonomic hyperreflexia well to help us really understand this condition let's break down its name and we're going to use the word hyperreflexia so hyper means excessive or exaggerated and reflex is talking about a reflex response so autonomic hyperreflexia or dysreflexia is an exaggerated reflex response by the autonomic nervous system and we're specifically talking about this sympathetic nervous system which is our fight or flight system now the autonomic nervous system is divided into two parts you have the sympathetic nervous system also you have the parasympathetic nervous system which is that rest and digest and in this condition this sympathetic nervous system reflex is really unopposed by this parasympathetic nervous system which is going to lead to severe hypertension now why is it occurring what's triggering it well it occurs due to some type of irritating stimulus that is occurring below the side of the spinal cord injury now not all patients who have a spinal cord injury are at a high risk for autonomic dysreflexia only patients who've had 86 or higher injury are at the highest risk of developing AD and whenever they do give this irritating stimulus it can trigger that reflex response by our sympathetic nervous system and lead to hypertension as I already pointed out and if this is uncontrolled it can lead to a stroke or a seizure and can be fatal so it is a medical emergency and as the nurse we play a very important role in preventing AD detecting it and acting on it appropriately which we're going to cover in our nursing interventions now how what causes ad what causes an irritating stimulus below that side of injury well there's really three big causes that can lead to this that I want you to remember and how I like to remember this is the three big beads so the most common cause of autonomic dysreflexia is a bladder issue like a urinary tract infection or a full distended bladder another cause is a bowel problem like hardened stool in the rectum where you have impaction and another B I want you to remember is breakdown of skin where that person has either maybe they're developing a pressure injury also called a pressure ulcer they have a cut in their skin they have a skin infection or maybe an ingrown toenail it's some type of irritating stimulus occurring below that side of injury now anything can really cause AD if it's providing that stimulation and some miscellaneous causes could be like menstruation and your female patient the birthing process or even sexual intercourse now let's break down the pathophysiology of autonomic dysreflexia so we know that we have an autonomic nervous system issue specifically an exaggerated reflex response by the sympathetic nervous system and our autonomic nervous system controls our involuntary functions that mean you can't do consciously so you have the autonomic nervous system it is divided into two branches sympathetic and parasympathetic and these systems work beautifully together but they oppose each other and we want them opposing each other because if one kicks in we want the other to be able to come in and maintain homeostasis of our body because for instance if we are constantly stimulating our sympathetic nervous system that fight-or-flight the body is going to wear out you're gonna stroke out or you're gonna have a seizure and die so we really need that Hara sympathetic nervous system to come say hey let's calm down a little bit so they can work together now our sympathetic nervous system as I've pointed out as a fight-or-flight so whenever you are perceiving something that's dangerous or you have an irritating stimulus in your body you're bought your sympathetic nervous system says hey we got to do something about so it causes your body to react and that will cause your brain to take care of the issue whether it's running away from that bear or it's as simple as emptying your bladder it will take care of that and how the sympathetic nervous system reacts to something is it causes vasoconstriction so it's gonna narrow your vessels down when we cause vasoconstriction that increases blood pressure so I want you to remember that concept vasoconstriction high blood pressure because that's one of the huge problems with this condition also it stimulates your sweat glands so you start to sweat it causes Branko dilation so you can breathe better increases your heart rate and it dilates your pupils so you can see better now your parasympathetic nervous system is going to do the opposite of the sympathetic because remember this system wants us to rest digest chill relax and reproduce and what it's going to do is it's going to cause vasodilation where vessels are going to widen and that's gonna drop your blood pressure it's also going to decrease your heart rate by stimulating the vagus nerve and I want you to remember these two functions of the parasympathetic system because here in a moment whenever we go into how ad really transpires it's gonna make a lot more sense about what's occurring above the site of injury versus what's occurring below the site of injury also your parasympathetic nervous system causes increased salivation it causes bronchoconstriction and it constricts your pupils so as you can see these systems they work beautifully together in opposing each other to keep things in check and imbalance in your body but it can only do this successfully if it has a healthy intact spinal cord so these messages can be sent in the body can react appropriately so if we sever this connection with like a spinal cord injury at six are higher we're going to create this disconnection between the parasympathetic and the sympathetic system now let's talk about what's occurring during autonomic dysreflexia so we've already established that in order for this condition to occur we have to have that irritating stimulus that's occurring below the site of injury and usually the most common cause is something to deal with the bladder so here we have a full bladder it is sending that irritating stimulus to our body which is causing our nerves to send impulses that hey something's wrong well normally this would go to the brain and the brain would say oh we have a full bladder and you would go in empty but here there is no communication remember it's being blocked through the spinal cord injury so instead this exaggerated sympathetic reflex response occurs and this is not just some normal sympathetic response that you have this is excessive exaggerated and what it's going to do is it's going to cause vasoconstriction of the vessels below the site of injury because remember we don't have a connection between really our upper and lower it's been severed so whenever we have this vasoconstriction these vessels are going to narrow together this is going to increase our overall blood pressure and how do you think the lower body is going to look compared to the upper body since we have vasoconstriction going on down here well it's going to be pail cool and clammy because we're really constricting blood flow to non bottle organs now because of this elevated blood pressure going on the body will sense it specifically these baroreceptors it doesn't know what's going on that there's an issue down here all it knows is that hey this blood pressure is high and these baroreceptors in the carotid sinus and the aorta say hey we can't maintain this so we are going to have to cause the parasympathetic system to kick in so we can bring this blood pressure down now whenever parasympathetic activity is stimulated it will cause vaso because remember that some of the things it does so our vessels are going to widen in hopes of decreasing blood pressure now they're widening up here but this parasympathetic nervous system impulses can't be sent down here because it's being blocked so we have vasodilation up here and they so constriction down here now how do you think the patient's going to look on the upper part of their body above that side of injury well they're going to be flushed because you have vasodilation it's increasing blood flow to the skin in addition this parasympathetic activity is going to try to slow the heart rate down because remember that was one of the things it does and so it'll stimulate that vagus nerve to do that and we'll get bradycardia because nothing's really wrong with the hurry to begin with so if we lower it even more we can get that heart rate less than 60 and all that is attempts by your body to decrease this blood pressure but it's not going to work this compensatory mechanism is not effective because we have basal constriction down here which is really taking over this pressure is going to stay high and elevate it until we can remove this irritating response and treat the patient appropriately so with all that pathophysiology in mind now let's look at the signs and symptoms and some things you need to watch out for as a nurse to detect if your patient is experiencing AD so one thing is a throbbing pounding headache they may report this and if they do you want to immediately check their blood pressure and this is from the elevated blood pressure another thing is hypertension and this is where the systolic is 20 to 40 millimeters of mercury higher than their baseline now patients with 86 or higher injury their systolic tends to run about ninety to a hundred and ten so let's say that their blood pressure their baseline is about 106 over 78 well you take it and it's 146 over 92 well that meets the criteria there are 40 millimeters of mercury higher and their systolic so you want to watch out for that look at that because in normal patients if we see 146 over 92 we're thinking wow it's a little bit high nothing too major but with patients who have a spinal cord injury you want to be worried about that also as we pointed out you'll see flushing on the area above the spinal cord injury and below it it will be pail cool and clammy and again that's due to the vaso constriction below the injury and the vasodilation above the injury also bradycardia where that heart rate is less than 60 they may experience goosebumps sweating dilated pupils have a stuffy nose and anxiety now let's wrap up this lecture and let's talk about nursing interventions so what are you going to do for this patient with autonomic dysreflexia well remember PDA as a nurse we play a huge role in prevention detection and action so first prevention you want to think of the three big B's as I discuss at the beginning of this lecture and what were they again bladder bowel and breakdown of skin these are usually the most common causes of autonomic dysreflexia but again remember anything below that side of injury that causes some type of irritating stimulus can lead to this so let's talk about bladder first again it's the most common cause so as a nurse you want to make sure your patient's bladder is being emptied properly you want to assess that urinary output make sure it's at least 30 CC's per hour also perform regular bladder scans to make sure that the bladder is not retaining urine and these are really easy to do you can get most units have these devices you take it to the bedside use ultrasound jelly and this probe and you scan the bladder and the Machine will tell you how much urine is in the bladder also you want to make sure you're taking measures to prevent urinary tract infections and one of these patients have Foley catheters so you want to make sure that you are providing proper Foley care assessing the color of the urine making sure that a urinary tract infection isn't presenting also if they do have a Foley catheter is it draining properly because these things are so easy to get kinked or blocked so always be assessing that tubing of the Foley catheter regularly and if it's blocked irrigation can be used to remove the blockage and let's say that for some reason the patient doesn't have a catheter and you need to drain the bladder well before you go in there and insert a Foley catheter this in itself is going to cause an irritating stimulus you want to use some type of anesthetic jelly whatever the doctor orders to help decrease that stimulation of that sympathetic reflex response another cause is a bowel issue and usually this is from impacted stool where a large amount of hard stool gets stuck in the rectum and this can provide an irritating stimulus so as a nurse you want to assess for bowel sounds palpate the abdomen do you feel distension any hard areas also assess their last bowel movement that's really important when did they last pass stool and you want to check for impaction if needed so what do you do if they're impacted well prior to actually removing the stool just like the Foley before you go in have to do something that is invasive like that you would want to use an anesthetic jelly to help numb the area and decrease that sympathetic reflex response and then break down of skin so as the nurse you want to make sure you're looking at your patient you're removing any binding devices or clothing that can be irritating to the skin especially below that side of injury repositioning the patient at least every two hours which is a minimum assessing their skin regularly looking it over are there any infections looking at their toenails looking at anything that's breaking down and protecting them from any pressure injury or getting hurt because again any cut bruises or anything can cause that irritating stimulus then we have detection and action so again just to recap who's the most at risk for autonomic dysreflexia those patients with T 6 or higher injuries and with these patients you always want to assess and monitor their blood pressure and we hit on this and signs and symptoms and an elevation of a systolic 20 to 40 millimeters of mercury more than baseline is something you definitely want to investigate and if your patient reports they have a headache you definitely immediately want to check their blood pressure see what their baseline is and how much has it elevated and you want to assess for those signs and symptoms of autonomic dysreflexia that we just covered that's part of just detecting if this is starting to occur looking at how does it look above the site of injury below it and what to do if these signs and symptoms present which ties into our action part because ad is a medical emergency so if you're in the hospital you want to call a rapid response and get help immediately because you're going to need help moving this patient because we want to position the patient at 90 degrees with their legs lowered now what this does is that this is going to cause gravity to allow blood to pulled out of those legs and help decrease the blood pressure also you're going to be assessing that blood pressure every two to five minutes remove any binding devices or clothing and then you want to investigate what causes what are the three big beads that we have to watch out for that tend to cause autonomic dysreflexia and you want to correct it we want to remove that irritating stimulus so what are we going to start with the most common so you'll start with the bladder is it full is there a urinary tract infection what's going on that's not the issue look at the bow do we have impaction and then proceed to the skin now sometimes we do all that and the blood pressure is still elevated that's when medications will need to be used to treat the autonomic dysreflexia some medications sometimes ordered by physicians are like nitropaste and on your Green you see a picture that's like an example of what nitropaste looks like and it's a topical application that goes on the skin now some things you want to remember about nitropaste or any type of nitro medications is that you do not want to administer them to a patient if they have taken a phosphodiesterase inhibitor in the past 24 hours this is like sadena fill or tadalafil which is Viagra and Cialis this can cause hypotension and another medication that can be ordered is like nifedipine which would be ordered like an immediate release route like sublingual so it can work fast and it's part of the calcium channel blocker family ok so that wraps up this lecture over autonomic dysreflexia thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos

Channel: RegisteredNurseRN

Views: 525,363

Keywords: autonomic dysreflexia, autonomic hyperreflexia, spinal cord injury, spinal cord injuries, nclex, spinal cord injuries nclex, autonomic dysreflexia nursing, autonomic dysreflexia nclex, autonomic dysreflexia treatment, autonomic dysreflexia symptoms, autonomic dysreflexia causes, nursing, autonomic dysrefelxia made easy, nursing school, rn, ati, hesi

Id: 7hLZjRP0p2U

Length: 18min 31sec (1111 seconds)

Published: Fri Jun 14 2019