InformationtoprovidetoHealthcareProfessionalspriortoadmissionofaSpinalCordInjuredpatienttoaDGHorNonSpecialistCentre

Inthefirstinstance,youshouldinformyourSpinalConsultant,ifpossible,aboutyourplannedadmissiontohospital.MedicalrecordscanbeappliedforfromyourSpinalCordInjuryCentre.

Askthe WardManager/Sisterifyourcarercanperformyourbowelmanagement,ifappropriate.Ifthisisnotpermitted,aretrainedstaffableto performyourroutinebowelmanagement?

Explainaboutanyspecificrequirementsyou have inrespectofpressurecare,e.g.apressurerelievingmattress,electricprofilingbedetc.

Askifthe Wardcarriessuppliesofthespecificcontinenceproducts youmayneed.

Completetheformbelowand sendacopytothe Ward Managerofthe wardtowhichyou arebeingadmittedandalsoensurethatyoutakeacopywithyouontheday.

Ifyourequireassistancewithcompleting theformorliaisingwithWardstaff,ringtheAdviceLine

Tel:08009800501or01908604191Ext203.

Name:Date:

NHSNumber:SCICNumber

To the Ward Manager / Sister

I haveTetraplegia/ Paraplegia– deleteasappropriate

Tetraplegia: Lossofmotorand/orsensoryfunctionin thecervical segmentsof thespinal cordresultingin impaired functioninhands,arms,trunk, legsandpelvicorgans.

Paraplegia:Lossofmotor and/orsensoryfunction inthethoracic,lumbar or sacral segments ofthespinal cord.Dependingon levelofinjury, thetrunk,legsandpelvicorgans maybe involved. Handandarmfunction is spared.

Thisdocumentcontainsmyspecificnursing requirements.

Pleaseseebelow current medications,whichhave beenprescribedbymyGP / SpinalConsultant.If the hospitalpermits,Iwill bringmymedications inwith me.

Theseare important issuesthat affectspinal cordinjuredpatientsthat Iwould likeyou to beawareof:

AutonomicDysreflexia(AD)

I amsusceptibletoAD andthefollowingmaytrigger an episode.Mysymptomsare likelytobe–see below –I have a fact sheet onAD whichyou can referto.

BowelCare

WhenI am admitted,please canI see a copyof thehospital’spolicyon DigitalRemovalofFaecesMybowelregimeconsists of thefollowing. Please canthis besharedwithanyonewhomayneedtoprovide mybowelmanagement.

Bladder Care

Mybladder regimeatpresentis (seebelow).Thecontinenceproducts Iuse are listedbelowe.gcatheter.I do/ donot have anallergyto latex.

PressureCare

Pressure reliefin SCI isvital topreventpressure ulcers.I havepartial or total lossofsensationbelowacertain level.

Spasms

I amaffectedbyspasms(involuntarymovements)in thefollowingwayandtakemedication to managetheseasindicatedbelow.

Spasms inSCI canbeverysevere / violent andmayoccur asawarningsign that somethingiswronge.g. a urinarytract infection,episodeofAutonomicDysreflexia. Individualpeoplemayhaveidentifiedpositionswhichwhilst on bedresthelpprevent orreducetheseverity oftheirspasms.

GeneralEquipmentCommunication Equipment

I require thefollowing equipmentandaids inorder tomaintainindependenceasmuch aspossible.CanthehospitalOTDept supplyequipmentthatfitsmylevelofSCI? Is therea Nurse CallSystemin place that I canuse?

Useful resourcesforHealthcareProfessionals working in DistrictGeneralHospitals,whoaretreating andmanaging SpinalCordInjuredpatients

  • Spinal CordInjuryCentres in theUK:

July-2014.pdf

  • MASCIP: MASCIPwebsite containsawealthofinformationincludinglinks toresources such astheBest PracticeGuidelinesandtheNationalSpinal CordInjuries Road Map -
  • RCN Booklet: Digital Rectal ExaminationandManualRemovalofFaecesMay2000, revised2012: Publicationcode:000934.
  • NationalPatientSafetyAgencyinformationnotice15/09/2004
  • SIA website:HealthProfessionals’Area–forguidanceandlinks:
  • SIA hasproduceda rangeoffreetodownloadfactsheetscoveringthemanyaspectsof SCI, suchas bladder, bowel andpressuremanagement

SIA Advice Line:Tel: 08009800501 orTel: 01908604191Ext 203Open 11am – 4.30pm,Monday-Friday.

SIAAcademy

TheSIAAcademyprovideseducationandtraininganddevelopssocial researchprojects.

Outreach Service: support in District GeneralHospitals(DGHs)and theCommunity

Forspinal cordinjuredpatientsbeing treatedin DGHs or othernon-specialist centres,support is availablethroughSIA'sOutreachService:

Theserviceprovidessupportforboththepatientandfamilymembers byallowingthemtotalkthroughtheimpactof suchaninjurywithsomeonewhounderstandsandwhocan signpostthem toothersourcesofhelpandsupport.

SIAOutreachServicealso offersfree InServiceTraining for NHSstaff.

Spinal InjuriesAssociation

SIA House,2TruemanPlace,OldbrookMiltonKeynes MK6 2HH

Tel:01908604191

FreephoneAdviceLineTel: 08009800501or 01908604191Ext203Email:.k

Website:

RegisteredCharityNo 1054097CharitableCompanyNo 3175203

Autonomic Dysreflexia

Whatisit?

Autonomic Dysreflexia isthenamegivento aconditionwhere thereisasudden and potentially lethalrise in blood pressure(BP).Itis yourbody’swayof responding to aproblem.Itis oftentriggered byacutepain orsomeotherharmful stimulus within the body.It isuniquetospinal cordinjuryandmost commonly affectsspinalcord injuredpeople with injuriesatoraboveT6. Thisextremerisein bloodpressure(hypertension)can lead tosometypesofstroke(cerebralhaemorrhage) and evendeath.

ItshouldALWAYS betreatedasamedicalemergency

Studieshave shownthatit canoccurat anytimefollowingthe onsetofspinalcordinjury,whenthe period ofspinal shock has subsided.Spinalcord injured peoplewith incompletelesionsarejustaslikelyto experienceautonomic dysreflexia aspeople with completelesions,(Harris2001)although it isreportedthatsymptomsarelesssevereinthisgroup.

Whydoesitoccur?

Autonomic dysreflexia occursinresponsetopainordiscomfortbelowthelevel ofspinal cord lesion.Itis the body’s‘fightorflight’response.Yourblood pressurerises when yourbodyencounters a harmful stimulus.

This isdetected bythe nervoussystem,whichthen responds,via theautonomic nervous system, bydilatingblood vessels,thereforeloweringblood pressuretotrytokeep it withinthenormal range.

When yourlevel ofinjuryisT6orabove, theautonomic nervous systemcannotlowerraised blood pressure belowyourlevelofinjury,inresponsetopainordiscomfortbelowthe levelofspinal cord injury.Hence,yourbloodpressurecontinues torise untiltheoffending stimulusis removed.

Howeveryourautonomicnervoussystemdoes makean attempt to loweryourblood pressureaboveyourspinalcord injury.Thisis the sourceofthe symptomsofautonomic dysreflexia which are aninvaluablewarningmechanismforyoutotakeappropriateaction.

If an autonomicdysreflexic episodeisnotresolved, the continuing surgeinblood pressure becomes verydangerousand canleadto astroke orpossiblydeath.

Whoisatrisk?

  • Spinal cord injured people injuredator above thelevel ofT6.
  • People with complete injuriesaremoreliketobeaffected.

Whatare thesymptoms?

  • Itshould benotedthatyoumaynotexperienceall the symptoms,youmight evenexperience symptoms that are peculiar toyou.
  • However one symptom thatisalwayspresent is:
  • Pounding,usuallyfrontal,headache

andoneormoreof thefollowing mostcommonpresentingsymptoms:

  • Flushed(red)appearance ofskin above thelevel ofinjury
  • Profusesweatingabove thelevel of injury
  • Pale coloured skinbelowthelevel ofinjury
  • Stuffynose
  • Non-drainage ofurine(urine obstruction isthemost commoncause)
  • Severe hypertension(note: sci peoplehave lowerrestingbpcomparedtonon-scipeople)
  • Thesensation ofatight chest
  • Bradycardia(slowingofthe heartrate)

Whatarethecommoncauses?Bladder

  • Distendedbladder
  • Akinkinthe catheter
  • An over-full legbag
  • Blockage orobstructionthatpreventsurineflowingfromthebladder
  • Urinarytract infection orbladder spasms
  • Bladder stones

Bowel

  • Distended bowelwhichcanbe duetoafull rectum,constipation orimpaction
  • Haemorrhoids
  • Analfissures
  • Stretching ofrectumoranusorskin breakdownin thearea

Skin

  • Pressureulcer, contactburn,scald orsunburn
  • Ingrown toenail
  • Tightclothing/legbagetc

Sexualactivity

  • Over-stimulationduringsexualactivity
  • Ejaculation –can causea dysreflexicepisode,but thiscanbemanaged

Gynaecologicalissues

  • Menstrualpain
  • Labouranddelivery

Othercauses

  • Bonefractures,belowthe level of injury
  • Pain ortrauma
  • Syringomyelia
  • Deep vein thrombosis(DVT)
  • Acuteconditions suchasgastric ulcer,appendicitis
  • Severeanxiety(eliminateallpossiblephysiologicalfactorsfirst)

Unlessthisisthefirsttime youhaveexperienced autonomicdysreflexia, orifyouare recentlyinjured,youwillusuallybe familiar withthe symptomsofautonomic dysreflexia in the same way apersonwith diabetesis aware oftheearlysymptomsofhypoglycaemia (lowblood sugar).Youmaywell beabletospottheproblemyourselfandtake immediateaction orgetappropriatehelp.

Not allmedical staff areaware of autonomicdysreflexia and you,as aspinal cord injured person,arean expertonyourcondition. Youmaywell find yourselfhaving toeducatea health professionalas towhat ishappening toyou.

WhilstsomeSCIpeopleinjured at T6andabove, willhave experienced atleast oneepisode ofautonomicdysreflexia during their rehabilitationin aSpinal CordInjuryCentre(SCIC), thiscannot beguaranteed.

Ideallythebestwayto experience the symptomsofautonomicdysreflexiaforthefirsttime, iswithin the protectiveenvironmentof aSCIC, wheremanyof theriskfactors that influence autonomicdysreflexia are wellcontrolled.

At your dischargeplanningstage, it isappropriatethat the CommunityCareTeamandyour fulltimecarers,have beeneducatedonthecausesand effects ofautonomic dysreflexia and they, in turn,should establishyourown currentknowledgeandexperienceforfuture reference.

Treatment

Earlyrecognition of ADisessential sothattreatment canbestartedimmediately.Once raised blood pressurehasbeenconfirmed, wherepossible,togetherwith the typical signsandsymptomsofautonomicdysreflexia, thehighblood pressuremustbetreatedandthe causeidentified.

Whatactionsshouldbetakenonceautonomicdysreflexiaisidentified?

  • Situpanddrop your feet
  • Loosen any clothingandchecknothingputtingpressure ontheskin
  • Performaquick assessmenttoidentifythecausesothatthestimulusmaybe removed.

Actions should beprioritisedas follows:

IdentifyandremovecauseBladder

Themostcommoncauseofautonomicdysreflexia isnon-drainage ofurine.Thiscanbe due toablockedcatheter,urinary tractinfection oroverfilledcollectionbag.

Action:

If youhave aFoleyor suprapubic catheter,check thefollowing:

  • Is yourdrainagebagfull?
  • Isthereakinkinthetubing?
  • Isthe drainage bag atahigher level than yourbladder?
  • Isthe catheterplugged?

Aftercorrecting the obviousproblem, and ifyourcatheter isnot drainingin2-3minutes,yourcathetermustbechangedimmediately.Ifyoudonothave aFoleyorsuprapubic catheter, performacatheterisationand emptyyourbladder.

DoNOTattemptabladderwashoutasthiscouldincreaseyourbloodpressure

Bowel

If yourbladderhasnottriggeredthe episodeofautonomicdysreflexia, thenthecausemaybe yourbowel.Thiscanbe dueto constipation,analfissures/haemorrhoidsoran infection.

Action:

Insert aglovedfingerlubricated with an anaesthetic lubricantsuchas 2%lignocainegel, into yourrectum.Iftherectumis full, insertsome lubricantand waitforaminimum of3minutes. Thisis toreducethe sensationintherectum whichisimportantas performingdigital stimulation andmanualevacuation mayworsenthe autonomic dysreflexia. Gentlyperformmanualevacuation.

Ifyouweredoingthiswhenthesymptomsofautonomicdysreflexiafirstappeared,thenstoptheprocedureandresumeafterthesymptomssubside

Othercauses

Ifan overfullrectum isn’tthecause,investigatealternative causesfromthelistgiven previously. It is importantthatifyou are havingan autonomicdysreflexicepisodethatyou remain calm;anxietycanmaketheproblemworse.Onceidentified,remove theoffending stimulus.

Ideallyyou,yourcarersandfamilymembers, should knowyournormalblood pressure.Itisimportantfor youtoknow yournormal blood pressureandpulserateanddocument theminan obviousplace, suchason yourcareplan,intheeventofyouhavinganepisode ofautonomicdysreflexia.

Aspeople with highlevelparaplegiaandtetraplegiausually have a lowresting blood pressure,(80 or90systolic fora cervical injury) ariseto120or130 systolic, couldbe dangerous.Ifyouhave an episode of ADitisimportanttobeabletogiveany attendant health professional yournormalbloodpressure.

IfpossiblerecordabaselineBP

If yourBP increasesby20mm/Hg andis accompanied bya loweringofthepulserate,then you could be havinganepisodeofautonomicdysreflexia.

If appropriate onceyouhave eliminatedbladderand bowel distensionas the cause of the autonomicdysreflexia, sit upand havefrequentBPchecks until theepisode hasresolved.

If you are unabletomeasure yourBPusingtheappropriatemeasuringmachine (sphygmomanometer) then agoodindicatoris the severity ofyourheadache.If yourBP continues torise,thenyourheadachewill becomemore intense;when it begins tofall,your headache willbelesspainful.

CallyourGP

Ifthesymptomspersist despite interventions, notifyyour GP andlocal SCIcentre.It isimportantthatyouarefamiliar with yourtreatmentoptionsintheeventof autonomic dysreflexia. Youshouldalso be providedwith anappropriatevasodilator (substancethat causesthe blood vesselstowiden,therebyreducingBP)foruse athome,which should be administeredifyouhaveanepisode ofautonomicdysreflexia.

Asmentioned previously, sincenotall medical and healthcarestaff arefamiliar with autonomicdysreflexia andits treatment,youshould carryanemergencymedicalcard withyoualwaysthatdescribesthecondition andthetreatmentrequired.You can obtain afree emergencymedical cardfromSIA.

AutonomicDysreflexiaEmergencyKit

Itisalso worthwhile to have an ADkitwith you atalltimes which wouldcontain:

  • Catheterandsupplies: ifyouuse intermittentcatheterisation,packastraight catheter, and ifyouusean indwellingcatheter,packinsertion supplies, irrigation syringeandsterile water/salinesolution.
  • Medicineprescribedforautonomicdysreflexia(usually NifedipineorGlyceryl tri-nitrate- GTN) –check thisfromtimetotimetomakesureit is in date
  • Anaesthetic lubricantlike2%lidocaine (lignocaine)gel
  • Sterilelatexgloves
  • Wetwipesanddisposalbag.

How canthe riskofautonomicdysreflexiabe reduced?Fortunatelythereareprecautionsyoucantaketoreducetheriskofautonomic dysreflexiaincluding:

Bladder

  • Changecatheters regularlyto prevent blockage
  • Keep cathetersfree offkinks,clean,andfollowyourintermittentcatheterisationregime regularly to avoid an overfull bladder
  • Check urineforsignsof infection(UTIs)
  • Have regularbladderand bowelcheck-ups withyourGPoratyourSCIC
  • Drink enoughfluids.

Bowel

  • Maintain a regularbowelregime(ideallyalternatedaysbetweenbowel evacuations)
  • Adequatefibre in diettohelpavoid constipation
  • Gettreatmentforhaemorrhoids.

Skin

  • Frequentpressurereliefwhen in both chairand bed
  • Check skinregularly
  • Avoidtight orrestrictiveclothing
  • Avoidance of sunburn/scalds(avoid overexposure,usesunscreenwith SPF15 orhigher, avoidextremewatertemperatures)
  • Establishgood posturein yourwheelchair
  • Maintainessential equipment,especiallymaking sure yourcushion isfitforpurpose.

Other

  • If pregnantorplanning togetpregnant,makesureyourobstetrician

/gynaecologistisaware of yourhealthcareneedsas aSCIperson

  • Correctdosageandtiming ofmedications
  • Be educatedin thecauses, signsandsymptoms,firstaid, andpreventionofautonomic dysreflexia andmake sure thosearoundyou,orcaringforyou, aresimilarlyeducated.

InSummary

  • ADis apotentiallylife-threatening medical problem
  • Itrequires immediateattention byyourself /yourcarers
  • Learn whattriggers an episode, howto dealwith it andteachthosearoundyouthe warning signs andtreatment
  • Have thenecessary toolshandytodeal with an episode
  • Fixthe problem,sit up andtryto staycalm
  • Call formedical attentionif the symptomsdonot subside.

ForanEmergencyMedicalCard,ringSIAAdviceLine–Tel:08009800501

*AdaptedfromManagingSpinalCordInjury:Continuing Care;Chapter22‘Autonomic Dysreflexia’by PaulHarrison Alison Lamb.

Posturalhypotension–(adropinbloodpressure)

Postural hypotension isadropin blood pressurewhenmoving fromaflattoanupright position.Ifyouhavea highspinalcordinjury,particularlyT6andabove,you may experienceafeeling offaintnessoryou maypassoutbriefly aftermovingtooquickly, forexample:

  • fromlyingdown tositting upinbed
  • shortlyaftertransferringinto your wheelchair
  • when standingin aframe.

Thefeeling offaintnessoccursbecause,as you situp,gravity allowsmore blood tomovedown into your legsand,due toyour paralysis,ithasdifficultyreturning up to yourheart. Thisleads toadrop inbloodpressure,making youfeelfaint.

Thereareseveral waysto overcomefaintness:

  • If youaresittinginbed,lie down again, waitforafewminutesandthensit up or elevate the back of thebedmoreslowly, sothatyousitupin bedinstages beforegettinginto yourwheelchair
  • If you areinyourwheelchair,ask ahelper to putthe brakes onandtilt yourwheelchair backwardsuntilyourhead and neck are nearlyhorizontal.A secondpersoncould lift yourfeetup.Waitforafewminutesandthefeeling should pass
  • Asan alternative itmaybepossiblefor youto leanforwardin yourchair.Ifyouare tetraplegic, takespecialcare ifyoudecidetodothis,as you couldoverbalance.It will be saferifyou are wearinga lapbeltand ifsomeone iswith you
  • Some people useted stockings orabdominal binders tolessentheeffectofgravity on blood pressure.Ifyouhave ongoingproblems fromlowblood pressure,speaktoyour doctor asmedicationcanalsohelp.

Theseactions will increase yourbloodpressure,and you willbegintofeelbetter,you can then beraised,orraise yourself,gradually. Youmayalsofindit helpfultohavea small drinkofwater.

UsingaStandingFrame

If you arestandingin astandingframe,youwill needtositbackdown inyourwheelchair andfollowthe advice given above.Ifthesensation offeelingfaintdoes notimprove or ifit reoccurs afewminutes later you mayneedtogoback tobedandlieflatfor awhile.

If youexperiencedifficultieswhenmoving fromlying tositting, itislikelythatyouwill have similar difficulties when standing.In preparation,trydrinkingaglass ofwater,itmay help. Youmayfeelfaintmorequicklyifyouhave notused thestandingframebefore,in which caseyourphysiotherapistwill be with you, or ifyouhave notstoodintheframeforsometime.

Althoughmostpeopleonlyexperience postural hypotensionforafewweekswhen theystart gettingup intoa wheelchairforthefirsttime,itcanbepersistent.Itmayalso occurifyou have been on bedrest foraperiod oftime, forexample,duetoapressureulcer.

Takecarewhen you startgettingupagain, youmaybetakenbysurprise!

Some people aremoreproneto posturalhypotensionthan others.Ifyouare,thenyou may need towear elasticated‘anti-embolism’stockings andan‘abdominal binder’,which islikeanelasticcorset,for afew weeks.

These will helptoprevent the bloodpoolinginthe lower partofyourbody,therebykeepingyourbloodpressure up. Makesureany compressiongarmentsyouusearenot tootightandthereforeliableto causepressureulcers.Eventually, asyourbodybeginsto adjust,youcanusuallystopwearing the abdominalbinder and later thestockings.

ExtractstakenfromSIA’spublication‘MovingForward–TheGuidetoLivingwithSpinalCordInjury’(2008)

Disclaimer

Thisfactsheethas beenpreparedbySIA andcontainsgeneraladviceonlywhichwe hopewillbeof useto you.Nothing inthisfactsheetshould beconstruedasthe givingof specific advice andit should not berelied on asabasis forany decision oraction.SIAdoesnotaccept any liability arisingfrom itsuse.Weaim toensuretheinformationisas up-to-dateandaccurateas possible,but pleasebe warnedthat certainareasaresubjectto changefrom timetotime.Pleasenotethatthe inclusionofnamedagencies,companies,products,servicesorpublications inthisfactsheetdoesnotconstitutearecommendationorendorsementby SIA.

RevisedMarch2013

AboutSIA

TheSpinalInjuriesAssociation(SIA)is theleadingnationaluser-ledcharityforspinal cordinjured (SCI) people.Beinguser led, weare well placedtounderstandthe everydayneedsofliving with spinal cord injury andare heretomeet thoseneedsby providingkeyservicestoshare information andexperiences,and to campaign for changeensuring each person can lead afullandactivelife.Wearehere tosupportyoufrom themoment yourspinalcordinjury happens,andfor therest ofyour life.

Formoreinformationcontactus viathefollowing:SpinalInjuries Association

SIAHouse

2TruemanPlaceOldbrook

MiltonKeynesMK6 2HH

T:01908604191(Mon–Fri9am–5pm)

T:08009800501(FreephoneAdviceLine,Mon–Fri,11am–1pm/2pm–4.30pm)

W:

@:arity No:1054097

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