Clinical protocol

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SIGNS AND SYMPTOMS Pounding usually frontal headache is always present

Severe hypertension (note spinal cord injured patients have a lower resting blood pressure) Slow pulse
One or more of the following Flushed appearance of the skin above the level of the injury

Kent Community Health NHS Foundation Trust Protocol for manual removal of faeces (acute) In adults over the age of 18 years V Page of July 2016 Profuse sweating above the level of the injury Pallor above the level of the injury Nasal congestion
TREATMENT Identify, remove or treat the most common cause for example non-drainage of urine, check for kinking in tubing, drainage bag full, blocked catheter. If catheter blocked, change catheter

never attempt a washout in this situation. If catheter is not the problem check for constipation, anal haemorrhoids or an infection. If constipation carryout usual bowel management. Under normal circumstances a tetraplegic person may have a low blood pressure (e.g.
90/ Arise to normal levels mm.Hg may represent a significant elevation. Regular monitoring of blood pressure is essential as changes can occur quickly monitor blood pressure every five minutes until blood pressure control is achieved. Each spinal unit has its own protocol therefore the nurse must familiarise themselves with the protocol for that patient, ensure it is the most up-to-date protocol and that the patient has telephone numbers for their spinal injury unit. Autonomic Dysreflexia is considered a medical emergency and nurses need to ensure that the patient has medication prescribed on an
‘Autho risation to Administer Medicines chart and that they are aware of location the medication stored in the patient’s house. Regular checks of the medication should be made to ensure that it has not passed its expiry date in case they need to administer the prescribed medication in an emergency. Administer the prescribed medication, monitor the patients blood pressure, if no response and blood pressure not responding, telephone for an emergency ambulance to take patient to Accident & Emergency Department or contact spinal unit for advice.

Clinical protocol
Executive summary
Governance arrangements
Related policies/procedures
Document tracking sheet
Contents page
Ethnicity and diversity
Roles and responsibilities
Training and awareness
Monitoring compliance and effectiveness of this policy
Monitoring matrix:
Equality analysis
Glossary and abbreviations
Appendix 2 bristol stool form scale
Knowledge and
Performance criteria
Appendix 3 care and management of autonomic dysreflexia
Common causes of autonomic dysreflexia.
Specialist advice

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