Nursing diagnosis – risk for autonomic dysreflexia

Risk for Autonomic Dysreflexia
DEFINITION
At risk for life-threatening, uninhibited response of the sympathetic
nervous system, post spinal shock, in an individual with spinal cord
injury or lesion at T6 or above (has been demonstrated in patients with
injuries at T7 and T8)
RISK FACTORS
An injury or lesion at T6 or above and at least one of the following
noxious stimuli:
• RISK FOR AUTONOMIC DYSREFLEXIA
Cardiac/pulmonary problems
• Deep vein thrombosis
• Pulmonary emboli
Gastrointestinal stimuli
• Bowel distension
• Constipation or fecal
impaction
• Digital stimulation
• Enemas
• Esophageal reflux
• Gallstones
• Gastric ulcers
• GI system pathology
• Musculoskeletal–integumentary
stimulation
• Cutaneous stimulation
(e.g., pressure ulcer, ingrown
toenail, dressings, burns, rash)
• Fractures
• Heterotrophic bone
• Pressure over bony prominences
• Pressure over genitalia
• Range of motion exercises
• Spasm
• Sunburns
• Wounds
Neurological stimuli
• Irritating stimuli below level
of injury
Regulatory stimuli
• Extreme environmental
temperatures
• Temperature fluctuations
Reproductive stimuli
• Ejaculation
• Labor and delivery
• Menstruation
• Ovarian cyst
• Pregnancy
• Sexual intercourse
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Elimination
EXPECTED OUTCOMES
The patient will
• Identify and reduce risk factors for dysreflexia.
• Avoid bladder distention.
• Will not experience a UTI.
• Maintain normal urinary and bowel elimination patterns.
• Be free from fecal impaction.
• Have an environment free from noxious stimuli that may cause
dysreflexia.
• Express understanding of causes of dysreflexia.
• Demonstrate understanding of measures to prevent dysreflexia.
• Neurocognition
• Risk management
SUGGESTED NOC OUTCOMES
Neurologic Status: Autonomic; Symptom Severity; Vital Signs Status
INTERVENTIONS AND RATIONALES
Determine: Assess for risk factors of dysreflexia, such as
constipation, fecal impaction, distended bladder, and presence of
noxious stimuli. Identifying risk factors can prevent or minimize
dysreflexic episodes.
Monitor and record intake and output accurately to ensure adequate
fluid replacement, thereby helping to prevent constipation.
Monitor vital signs frequently to ensure effectiveness of preventive
measures. Severe hypertension may indicate dysreflexia.
Perform: Check for bladder distention and patency of catheter. A
blocked catheter can trigger dysreflexia.
Check for abdominal distention and assess bowel sounds. Monitor
and record characteristics and frequency of stools. Fecal impaction
may lead to dysreflexia.
Administer laxative, enema, or suppositories, as prescribed, to
promote elimination of solids and gases from GI tract. Monitor
effectiveness.
Implement and maintain bowel and bladder programs to avoid
stimuli that could trigger dysreflexia.
Inform: Instruct patient, family member, or caregiver about risk factors,
signs and symptoms, and care measures for dysreflexia to help
prevent a possible dysreflexic episode and help him or her respond
appropriately should dysreflexia occur.
Attend: Encourage fluid intake of 21⁄2 qt (2.5 L) daily, unless
contraindicated. Adequate fluid intake helps maintain patency of
catheter and aids bowel elimination.
Manage: Consult with dietitian about increasing fiber and bulk in
diet to maximum prescribed by physician to improve intestinal muscle
tone and promote comfortable elimination.
SUGGESTED NIC INTERVENTIONS
Dysreflexia Management; Neurologic Monitoring; Vital Signs Monitoring
Reference
Joseph, A. C., & Albo, M. (2004, October). Urodynamics: The incidence of
urinary tract infection and autonomic dysreflexia in a challenging population.
Urologic Nursing, 24(5), 390–393.

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