Autonomic Dysreflexia

Autonomic dysreflexia
Autonomic dysreflexia is a condition that occurs in individuals with spinal cord injuries above the T6 level. It is characterized by a sudden and severe increase in blood pressure, often accompanied by other symptoms such as headaches, sweating, and flushing of the skin. In this blog post, we will discuss the NANDA nursing diagnosis for autonomic dysreflexia, as well as the defining characteristics, related factors, risk population, and associated problems. We will also provide suggestions for use, alternative NANDA diagnoses, usage tips, lists of NOC and NIC interventions, and conclude with a summary of the importance of understanding and addressing autonomic dysreflexia.

NANDA Nursing Diagnosis Definition

According to NANDA International, the nursing diagnosis for autonomic dysreflexia is defined as “sudden, exaggerated autonomic response to a stimulus below the level of injury.” This diagnosis can be made when a patient with a spinal cord injury above the T6 level experiences a sudden and severe increase in blood pressure, often accompanied by other symptoms such as headaches, sweating, and flushing of the skin.

Defining Characteristics

Subjective

  • Patient reports severe headache
  • Patient reports sweating or flushing of the skin
  • Patient reports nausea or vomiting

Objective

  • Sudden and severe increase in blood pressure
  • Flushing or sweating of the skin
  • Rapid or pounding pulse
  • Headache or blurred vision
  • Nausea or vomiting

Related Factors

  • Spinal cord injury above the T6 level
  • Stimuli below the level of injury, such as bladder or bowel distention, pressure ulcers, or tight clothing
  • Certain medical conditions or medications that affect blood pressure

Risk Population

Individuals with spinal cord injuries above the T6 level are at risk for autonomic dysreflexia. Additionally, those with certain medical conditions or who take certain medications that affect blood pressure may be at risk.

Associated Problems

Autonomic dysreflexia can lead to a variety of health problems, including:

  • Stroke
  • Seizures
  • Heart attack
  • Organ damage
  • Death

Suggestions for Use

  • Assess the patient’s blood pressure and other vital signs
  • Identify any stimuli that may be contributing to the patient’s autonomic dysreflexia, such as bladder or bowel distention, pressure ulcers, or tight clothing
  • Implement interventions to lower the patient’s blood pressure and remove the stimuli causing the dysreflexia
  • Monitor the patient’s response to interventions and adjust as needed
  • Provide education and resources to the patient and their family about preventing autonomic dysreflexia and recognizing the signs and symptoms
  • Implement safety measures, such as a bed alarm, to prevent pressure ulcers and other stimuli that may cause autonomic dysreflexia

Suggested Alternative NANDA Diagn

  • Hyperreflexia, Autonomic
  • Hypertonic, Autonomic
  • Hypertensive episode, Autonomic

Usage Tips

  • Be aware of the patient’s risk factors and environment, such as a spinal cord injury above the T6 level
  • Monitor the patient’s vital signs, including blood pressure, to detect autonomic dysreflexia early
  • Implement interventions to lower the patient’s blood pressure and remove the stimuli causing the dysreflexia
  • Implement safety measures, such as a bed alarm, to prevent pressure ulcers and other stimuli that may cause autonomic dysreflexia

NOC Results with Explanation

  1. Blood pressure: The patient’s blood pressure will be monitored and interventions will be implemented to lower it to a normal range.
  2. Cardiac output: The patient’s cardiac output will be monitored to ensure that it is not compromised due to autonomic dysreflexia.
  3. Respiratory status: The patient’s respiratory status will be monitored to ensure that it is not compromised due to autonomic dysreflexia.
  4. Neurological status: The patient’s neurological status will be monitored to ensure that it is not compromised due to autonomic dysreflexia.
  5. Skin integrity: The patient’s skin will be monitored for integrity and to ensure that it is not compromised due to autonomic dysreflexia.

NIC Interventions with Explanation

  1. Blood pressure management: The patient’s blood pressure will be lowered using medication or other interventions.
  2. Stimuli management: The stimuli causing the autonomic dysreflexia, such as bladder or bowel distention, pressure ulcers, or tight clothing, will be removed.
  3. Monitoring and assessment: The patient’s vital signs and response to interventions will be closely monitored and assessed.
  4. Education and resources: The patient and their family will be provided with education and resources regarding preventing autonomic dysreflexia and recognizing the signs and symptoms.
  5. Safety measures: Safety measures, such as a bed alarm, will be implemented to prevent pressure ulcers and other stimuli that may cause autonomic dysreflexia.

Conclusion

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries above the T6 level. It is characterized by a sudden and severe increase in blood pressure, often accompanied by other symptoms such as headaches, sweating, and flushing of the skin. It is important for healthcare professionals to understand the diagnosis, related factors, and interventions in order to provide effective care for patients. Assessing the patient’s blood pressure, identifying contributing factors, and implementing interventions to lower the patient’s blood pressure and remove the stimuli causing the dysreflexia can help to improve patient outcomes and prevent complications. It is also important to provide education and resources to the patient and their family about preventing autonomic dysreflexia and recognizing the signs and symptoms. With proper understanding and management, healthcare professionals can effectively address and prevent autonomic dysreflexia.

Related posts:

Leave a Comment