+ What are the key components of this patient’s history and physical examination, and why?

Relevant History:

• What is the context of the shortness of breath and headache? Acute? Chronic? What was the patient doing when these symptoms arose?
• Is there associated cough, other pains, fever, chills, vision or hearing changes, nausea, vomiting, sensation changes, rash?
• Is the patient requiring oxygen?
• Has this ever happened before?
• What is the complete etiology and history of the SCI? What is the most recent ASIA test result?
• Functional history and current functional status, including equipment usage?
• Past Medical and Surgical History?
• Medications?
• Allergies?

Relevant Physical Examination:

• What are the vital signs?
• Cardiopulmonary exam
• Integumentary exam
• Brief neurological and musculoskeletal exam

+ What is your differential diagnosis for this patient's shortness of breath?

• Autonomic dysreflexia, myocardial infarction, angina, pulmonary embolism, pain response, cardiac dysrhythmia, urinary tract infection, sepsis, pneumonia, fatigue, cardiac overload, anemia, anxiety, thyroid disease, subarachnoid hemorrhage.

+ What is your next step?

• I am concerned most immediately with autonomic dysreflexia. Thus, I would proceed as follows:
• Stat vital signs check if not already performed. Recheck 5 minutes after the most recent check.
• Sit the patient up, loosen clothing, straight catheterize the bladder, empty bowels.
• If not improving vital signs and symptoms with these acute measures, apply topical nitroglycerin ointment to the chest. If blood pressure does not sufficiently decrease, give nifedipine chew, and consider adding clonidine or captopril. If blood pressure is still not improving, would order a rapid response, as her symptoms are very consistent with autonomic dysreflexia, which can cause stroke, seizure, subarachnoid hemorrhage, myocardial infarction, and/or death. She will require IV blood pressure medication at that point.

+ How would you manage the patient at this point?

• I would educate the patient on the diagnosis of autonomic dysreflexia, what it entails, why it is serious and important to prevent and/or treat, and what the patient can do now and in the future to prevent its occurrence or treat it if it does occur. I would specifically educate her on avoiding common triggers such as tight clothing, overfull bladder or bowels, skin breakdown, and poor toenail care. In her case I would specifically spend time discussing her bladder output of 900cc of urine, which was likely her trigger for this episode of autonomic dysreflexia. I would educate on proper catheterization volumes and a bladder emptying schedule to maintain good bladder health and prevent further autonomic dysreflexia.

+ How would you address or attempt to correct this issue?

• I would take the time to educate the nursing staff about the diagnosis, causes, sequelae/complications, and treatment for autonomic dysreflexia, including how to properly identify it (AD commonly presents with elevated blood pressure 20 mmHg or greater above baseline, sweating, bradycardia, and headache), and how to reflexively treat it (sit the patient up, loosen clothing, empty bladder, check skin, empty bowel, call doctor). With improved education and training, call volume should reduce for cases of inappropriately suspected autonomic dysreflexia. I would ensure that all questions asked by nursing staff are answered satisfactorily. I would emphasize that if there is any hesitation whatsoever on whether or not AD is taking place, please call the on-call physician stat for guidance.

+ What is your response?

• I would ask for a stat set of vital signs, if not already taken; if available, I would ask what the full set of vital signs is. I would ask for the patient’s full set of symptoms, including specifically headache, sweating, chest pain, and shortness of breath. I would ask if any immediate action has been taken to treat the suspected AD except for applying nitropaste.

+ The nurse responds:

• “We emptied his bladder and only 200cc of urine came out. The nitropaste isn’t helping. You need to get here now because your directions are not working.”

+ Your response?

• It sounds like you are rightfully concerned about this patient. Thank you for bringing him to my attention; please tell me more about what you’ve already tried.

• Nurse: "That's it."

+ Your response?

• Ok, then we need to take further action together. Please sit the patient up, loosen his clothing, check his skin for signs of breakdown, and if not improving, evacuate his bowels.

• Nurse: “His clothing looks loose enough, but we will sit him up. There was no report of any wounds from the day shift nurse. I will call and see if there is anyone available for bowel emptying.”

+ Your response?

• Please take care of checking his skin directly for breakdown, loosen his clothing directly, sit the patient up, and then empty his bowels, as full bowel may cause autonomic dysreflexia and this needs to be addressed for his safety. There is no time to call for anyone else and you must take immediate action to address all of these steps, with the final step being bowel emptying.

• Nurse: “Well I can tell you that’s definitely not within my job duties, so he will have to wait while I call for an aide.”

+ Your response?

• This patient’s clinical status is an emergency right now. We need to act immediately. The patient is not safe while we delay care. Is there another nurse in your immediate vicinity whom I could speak to right now? If not, I will call for a rapid response and will direct the rapid response team via telephone.

• Note: You may occasionally encounter individuals who are reluctant to perform unsavory tasks. It is your job to maintain patient safety above personal ego at all times. You must remain firm and professional in the name of patient safety, and do not accept “no” when directing treatment. In reality, during daytime hours it would be appropriate to approach this nurse in person and discuss what happened overnight. If the nurse is still disagreeable, it would be appropriate to bring up this nurse’s refusal to provide care with the nurse manager in the name of patient safety.