Clinical protocol

Autonomic Dysreflexia : A Flow Chart for Health Care Professionals

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Autonomic Dysreflexia : A Flow Chart for Health Care Professionals Autonomic Dysreflexia (AD) is a potentially life-threatening condition that occurs in individuals with a spinal cord injury (SCI) at level Tor above (McLeod 2004). A patient with an SCI may have a resting blood pressure of 90/60mmHg, hence readings of
120/80mmHg might represent a considerable elevation in blood pressure. Signs and symptoms of AD Hypertension. Severe throbbing headache, bronchospasm, nasal congestion, blurred vision, sweating and/or flushing above level of injury, and palpitations. Individuals may experience more than one symptom If not contraindicated, the patient should be placed in an upright position to induce postural hypotension. Blood pressure should betaken on both arms and repeated every three minutes. A drop in blood pressure will occur with the removal of the noxious stimuli Call an ambulance Administer antihypertensive agents or glyceryl trinitrate to control hypertensive effects. Loosen clothing and check for noxious stimuli below level of injury Check for bladder distension. Catheterise bladder using Instilagel. If indwelling catheter already in place, inspect for kinks, folds, constriction or obstruction. Replace catheter to insure patency. DO NOT USE CATHETER MAINTENANCE SOLUTIONS. Collect urine sample and send for
MC&S (irritation maybe due to infection. Males Genitalia pinched

correct. Sheath too tight

remove Females Menstrual cramping

treat. Vaginitis - treat symptoms and infection Check bowel for constipation and if necessary perform digital removal of faeces Evaluate for high impaction. Monitor blood pressure until it is within normal range for individual.

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 References Ash D. (2005) Sustaining Safe and Acceptable Bowel Care in Spinal Cord Injured Patients. Nursing Standard 20, 8, 55-64. McLeod A (2004) Traumatic Injuries to the Head and Spine 2: Nursing Considerations. British
Journal of Nursing. 13, 17, 1041-1049. Spinal Injuries association (2010) Continuing Healthcare. Available at
Walker J (2009) Spinal cord injuries Acute Care Management and Rehabilitation.
Nursing Standard. 23, 42, 47-56.

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.
Signs and symptoms
Specialist advice

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