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.

Nursing diagnosis – autonomic dysreflexia

Autonomic Dysreflexia
DEFINITION
Life-threatening, uninhibited sympathetic response of nervous system
to noxious stimulus after spinal cord injury at T7 or above
DEFINING CHARACTERISTICS
• AUTONOMIC DYSREFLEXIA
• Paroxysmal hypertension (sudden
periodic elevated blood pressure,
systolic over 140 mm Hg
and diastolic over 90 mm Hg)
• Bradycardia or tachycardia
(pulse less than 60 or more
than 100 beats/min) Diaphoresis
above injury
• Red splotches (vasodilation)
on skin above injury
• Pallor below injury
• Diffuse headache not confined
to any nerve distribution area
• Bladder distention
• Bowel distention
• Lack of caregiver and patient
knowledge
• Chilling
• Conjunctival congestion
• Horner’s syndrome (contracted
pupils, partial ptosis, enophthalmos,
loss of sweating on
affected side of face
[sometimes])
• Paresthesia
• Pilomotor reflex
• Blurred vision
• Chest pain
• Metallic taste
• Nasal congestion
RELATED FACTORS
• Bladder distension
• Bowel distension
• Deficient caregiver knowledge
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Elimination
EXPECTED OUTCOMES
The patient will
• Have cause of dysreflexia identified and corrected.
• Experience cardiovascular stability as evidenced by ____ systolic
range, ____ diastolic range, and _____ heart rate range.
• Avoid bladder distention and urinary tract infection (UTI).
• Have no fecal impaction.
• Have no noxious stimuli in environment.
• State relief from symptoms of dysreflexia.
• Have few, if any, complications.
• Maintain normal bladder elimination pattern.
• Maintain normal bowel elimination pattern.
• Demonstrate knowledge and understanding of dysreflexia and will
describe care measures.
• Experience few or no dysreflexic episodes.
• Deficient patient knowledge
• Skin irritation
• Neurocognition
• Risk management
SUGGESTED NOC OUTCOMES
Neurologic Status; Neurologic Status: Autonomic; Sensory Function
Status; Vital Signs Status
INTERVENTIONS AND RATIONALES
Determine: Assess for signs of dysreflexia (especially severe hypertension)
to detect condition so that prompt treatment may be initiated.
Take vital signs frequently to monitor effectiveness of prescribed
medications.
Perform: Place patient in a sitting position or elevate the head of bed
to aid venous drainage from brain, lower intracranial pressure, and
temporarily reduce blood pressure.
Ascertain and correct probable cause of dysreflexia. Check for
bladder distention and patency of catheter. If necessary, irrigate
catheter with small amount of solution, or insert a new catheter
immediately. A blocked urinary catheter can trigger dysreflexia.
Check for fecal mass in rectum. Apply dibucaine ointment (Nupercainal)
or another product, as ordered, to anus and 1 (2.5 cms) into
rectum 10–15 min before removing impaction. Failure to use
ointment may aggravate autonomic response.
Check environment for cold drafts and objects putting pressure on
patient’s skin, which could act as dysreflexia stimuli. Send urine for
culture if no other cause becomes apparent to detect possible UTI.
Implement and maintain bowel and bladder elimination programs
to avoid stimuli that could trigger dysreflexia
Inform: Instruct patient, family members, or caregiver about dysreflexia,
including its causes, signs and symptoms, and care measures to prepare
them to handle possible emergencies related to condition.
Attend: Reassure patient that everyone involved in his or her care
will be instructed in management of this problem to relieve anxiety.
Manage: If hypertension persists despite other measures, administer
ganglionic blocking agent, vasodilator, or other medication as ordered.
Drugs may be required if hypertension persists or if noxious stimuli
can’t be removed.
SUGGESTED NIC INTERVENTIONS
Dysreflexia Management; Neurologic Monitoring; Surveillance; Temperature
Management; Vital Signs Monitoring
Reference
Karlsson, A. K. (2006). Autonomic dysfunction in spinal cord injury: Clinical
presentation of symptoms and signs. Progress in Brain Research, 152, 1–8