NEUROLOGICAL SYSTEM

1. Problems include autonomic dysreflexia (a medical emergency that can lead to cerebral
infarction, intracerebral hemorrhage, seizures, myocardial infarction, and even
death),pain, paresthesia, hyperesthesia, and sleep disorders (particularly in patients with
high quadriplegia)
2. Causes include:
o Scar tissue or posttraumatic sympathetic dystrophy
o Recovery from spinal shock which involves the return of:

Some reflexes, which can create an exaggerated response in patients with

lesions at T6 and above due to a lack of control from higher centers

Sensations, ranging from tingling to severe pain, particularly at the level

of the injury, due to the loss of downstream inhibition, realignment of
structural and sympathetic connections, release of excitatory pathways,
regrowth of neurons in the area of the injury, and the activation of
secondary nociceptive pathways

o Noxious stimuli below the level of injury, which can trigger autonomic
dysreflexia, such as distended bladder, constipation or fecal impaction, pressure
sores, etc.
o Hypoxia, which can cause serious nocturnal hypoxic episodes, and respiratory
muscle paralysis or weakness, which can cause sleep-induced respiratory
problems.
3. Nursing Diagnoses include hypothermia, knowledge and self-care deficits, impaired
physical mobility and swallowing, sensory/perceptual alterations, sexual dysfunction,
sleep pattern disturbance, risk of injury, pain, and autonomic dysreflexia, which presents
with:
o Headache (may be pounding or severe)
o Paroxysmal hypertension (blood pressure 20 mm Hg above baseline, which is
frequently lower than normal in SCI patients) and flushing of face and neck
o Bradycardia
o Profuse sweating above the level of injury
o Piloerection (goose flesh) below the level of injury

o Chills without fever, basal congestion, and bronchospasm

o Blurred or tunnel vision and anxiety/apprehension
4. Assessments include assessing baseline and monitoring highest sensory level, motor
function, and reflexes; monitoring vital signs and complaints of pain or abnormal
sensations; MRI or CT scans and x-rays of spine; and monitoring for signs and symptoms
of autonomic dysreflexia
5. Nursing Interventions include:
o Providing for total care needs of patient
o Providing information to patient and family
o Treating autonomic dysreflexia:

Elevate the head immediately to a 90 degree angle and place the legs in a
dependent position, if possible, to lower the blood pressure

Loosen constrictive clothing, antiembolic hose, abdominal binders, etc.

Remove noxious stimuli, such as a distended bladder, constipation or fecal

impaction, urinary calculi, cystitis, acute abdominal lesions, operative
incisions, uterine labor contractions, pressure on the glans penis, and
stimulation from skin lesions

Check and irrigate catheter immediately, or replace, if obstructed

Catheterize patients on intermittent catheterization immediately

Anesthetize with a topical ointment and then disimpact the lower

bowel, if stool is present

Anesthetize with a topical spray, if pressure ulcer is the noxious

stimulus

Monitor blood pressure every 2-3 minutes and vital signs every 5 minutes

Administer drugs to lower the blood pressure, if necessary

o Evaluating pain and pain control via drugs, imagery, biofeedback, relaxation
techniques, and surgery, such as dorsal column stimulation or surgical ablation of
the dorsal root of the spinal cord

o Beginning patient/family teaching to prevent autonomic dysreflexia and injury to

tissue, and using comfort measures
o NEUROLOGICAL SYSTEM
o Problems include autonomic dysreflexia (a medical emergency that can lead to
cerebral infarction, intracerebral hemorrhage, seizures, myocardial infarction, and
even death),pain, paresthesia, hyperesthesia, and sleep disorders (particularly in
patients with high quadriplegia)
o Causes include:
o Scar tissue or posttraumatic sympathetic dystrophy
o Recovery from spinal shock which involves the return of:
o Some reflexes, which can create an exaggerated response in patients with lesions
at T6 and above due to a lack of control from higher centers
o Sensations, ranging from tingling to severe pain, particularly at the level of the
injury, due to the loss of downstream inhibition, realignment of structural and
sympathetic connections, release of excitatory pathways, regrowth of neurons in
the area of the injury, and the activation of secondary nociceptive pathways
o Noxious stimuli below the level of injury, which can trigger autonomic
dysreflexia, such as distended bladder, constipation or fecal impaction, pressure
sores, etc.
o Hypoxia, which can cause serious nocturnal hypoxic episodes, and respiratory
muscle paralysis or weakness, which can cause sleep-induced respiratory
problems.
o Nursing Diagnoses include hypothermia, knowledge and self-care deficits,
impaired physical mobility and swallowing, sensory/perceptual alterations, sexual
dysfunction, sleep pattern disturbance, risk of injury, pain, and autonomic
dysreflexia, which presents with:
o Headache (may be pounding or severe)
o Paroxysmal hypertension (blood pressure 20 mm Hg above baseline, which is
frequently lower than normal in SCI patients) and flushing of face and neck
o Bradycardia
o Profuse sweating above the level of injury

o Piloerection (goose flesh) below the level of injury

o Chills without fever, basal congestion, and bronchospasm
o Blurred or tunnel vision and anxiety/apprehension
o Assessments include assessing baseline and monitoring highest sensory level,
motor function, and reflexes; monitoring vital signs and complaints of pain or
abnormal sensations; MRI or CT scans and x-rays of spine; and monitoring for
signs and symptoms of autonomic dysreflexia
o Nursing Interventions include:
o Providing for total care needs of patient
o Providing information to patient and family
o Treating autonomic dysreflexia:
o Elevate the head immediately to a 90 degree angle and place the legs in a
dependent position, if possible, to lower the blood pressure
o Loosen constrictive clothing, antiembolic hose, abdominal binders, etc.
o Remove noxious stimuli, such as a distended bladder, constipation or fecal
impaction, urinary calculi, cystitis, acute abdominal lesions, operative incisions,
uterine labor contractions, pressure on the glans penis, and stimulation from skin
lesions
o Check and irrigate catheter immediately, or replace, if obstructed
o Catheterize patients on intermittent catheterization immediately
o Anesthetize with a topical ointment and then disimpact the lower bowel, if stool is
present
o Anesthetize with a topical spray, if pressure ulcer is the noxious stimulus
o See also the clinical practice guidelines forAutonomic Dysreflexia from the
Consortium for Spinal Cord Medicine
o Monitor blood pressure every 2-3 minutes and vital signs every 5 minutes
o Administer drugs to lower the blood pressure, if necessary

o Evaluating pain and pain control via drugs, imagery, biofeedback, relaxation
techniques, and surgery, such as dorsal column stimulation or surgical ablation of
the dorsal root of the spinal cord
o Beginning patient/family teaching to prevent autonomic dysreflexia and injury to
tissue, and using comfort measures

http://calder.med.miami.edu/providers/NURSING/neuro.html
http://www.slideshare.net/dsukumaran/autonomic-dysreflexia-nursing-care