00009 Autonomic dysreflexia

Domain 9: coping/stress tolerance
Class 3: neurocomported stress
Diagnostic Code: 00009
Nanda label: autonomous dysreflexia
Diagnostic focus: Autonomous dysreflexia
Approved 1988 • Revised 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « autonomous dysreflexia »  is defined as: non -inhibited response, threatening for life, of the sympathetic nervous system before a harmful stimulus after a medullary lesion at the level of the seventh vertebra dorsal (d7) or higher.

Definite characteristics

  • Blurred vision
  • Bradycardia
  • chest pain
  • Internal feeling of intense cold
  • Conjunctival hyperemia
  • Diaphoresis above the lesion
  • Diffuse pain in different areas of the head
  • Horner syndrome
  • Metallic flavor in the mouth
  • Nasal congestion
  • pale below the injury
  • Paresthesia
  • paroxysmal hypertension
  • Pilomotor reflex
  • Red spots on the skin above the lesion
  • Tachycardia

Related factors

Gastrointestinal stimuli

  • Intestinal distension
  • Constipation
  • Difficulty defecating
  • Digital stimulation
  • Enemas
  • Fecal impact
  • Suppositories

Tegumentary stimuli

  • Cutaneous stimulation
  • Skin irritation
  • Solar burns
  • Wounds

Musculoskeletic-neurological stimuli

  • Irritative stimuli below the level of the lesion
  • Muscle spasm
  • Painful stimuli below the level of the lesion
  • Bone prominence pressure
  • Pressure on the genitals
  • Movement amplitude exercises

Regulatory and Situational Stimuli

  • Adjusted clothing
  • Fluctuation in ambient temperature
  • Posture

Reproductive-urological stimuli

  • Black distension
  • Black spasm
  • Use of instruments
  • Sexual relations

Other factors

  • Inappropriate knowledge of the caregiver (a) on the disease process
  • Inappropriate knowledge of the disease process

Risk population

  • People exposed to extreme environmental temperatures
  • Men with spinal cord injury or injury that experience ejaculation
  • Women with spinal cord injury that experience childbirth
  • Women with spinal cord injury are menstruating
  • Women with spinal cord injury that are pregnant

Associated problems

  • Bone fractures
  • Detrusor sphincter Dysinergia
  • Digestive system diseases
  • Epididimitis
  • heterotopic bone
  • Ovarian cyst
  • Pharmacological preparations
  • kidney stones
  • Abstinence syndrome
  • Surgical procedures
  • Urinary catheterization
  • Urinary tract infection
  • Venous thromboembolism

Suggestions of use

Autonomous dysreflexia is a potential problem of the patient with upper core and cannot continue as a diagnosis of real nursing. If independent nursing activities do not solve it, medical treatment is necessary. In general, the risk of autonomous dysreflexia is a more useful diagnosis than autonomous dysreflexia because most of the time the patient is in a potential state (Carpenito-Moyet, 2006b, p. 285). Suggested alternative diagnoses correspond to harmful stimuli that can trigger a sympathetic response in the patient who suffers a spinal cord injury. They can be used as real problems or as the etiology of autonomous dysreflexia or risk of autonomous dysreflexia.

Suggested alternative diagnostics

  • Constipation
  • Cutaneous integrity, deterioration of the
  • Urinary retention

NOC Results

  • Neurological status: Capacity of central and peripheral nervous systems to receive, process and respond to internal and external stimuli
  • Neurological state: Autonomous: Autonomic nervous system capacity to coordinate visceral and homeostatic function
  • Vital signs: measure that temperature, pulse, breathing and TA are within normal values ??

Evaluation objectives and criteria

  • The patient does not experience autonomous dysreflexia, as demonstrated
  • The patient demonstrates a satisfactory neurological state, evidenced by the following indicators (specifying 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Consciousness
    • Central motor control
    • Cranial sensory and motor functions
    • Respiratory pattern

Other examples

The patient will be able to:

  • Keep vital signs in the expected range: temperature, apical and radial pulses, respiratory rate, systolic and diastolic ta
  • Demonstrate ability to maintain defecation and urination routine
  • Identify the early signs and symptoms of dysreflexia (for example, headache, blurred vision, paresthesia)

NIC Interventions

  • Dysreflexia management: prevention and elimination of stimuli that cause hyperactive reflections and inappropriate autonomous responses in a patient with a cervical core lesion or the top of the thorax
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
  • Skin surveillance: Patient data collection and analysis to maintain the integrity of skin membranes and mucous membranes
  • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications

Nursing Activities

Valuations

  • Evaluate the patient’s knowledge about his condition, including the history of previous episodes, early signs and symptoms, as well as defecation and urination habits
  • Evaluate skin status at least once a day, registering any reddened area above the level of the spinal cord lesion
  • Measure the basal temperature, the ta and the pulse
  • (NIC) Dyrephlexia management: monitor the signs and symptoms of autonomous dysreflexia: paroxysian hypertension, bradycardia, tachycardia, diaphoresis above the level of lesion, facial blush, paleness under the level of injury, headache, congestion nasal, congestion of the temporal and neck vessels, congestion of the conjunctiva, chills without fever, pylomotora and chest pain

Patient and family education

  • Ask the patient to report any sign and early symptoms of the problem
  • (NIC) Dyrustee management: instruct the patient and family about the causes, symptoms, treatment and prevention of dysreflexia

Collaboration activities

  • (NIC) Dyrustee management: administer intravenous antihypertensive drugs, as ordered by

Others

  • (NIC) Dyrephlexia management: identify and reduce stimuli that can precipitate dysreflexia (bladder distension, kidney stones, infection, fecal impact, rectal touch, supplying of suppositories, skin break and clothing or tight sheets, etc.
  • If the symptoms occur, interrupt the activity and ask someone to notify the doctor
  • Quickly eliminate harmful stimuli in the following order:
    • Bladder: Check that the probe is permeable or place probe to the patient
    • Intestines: if you are relaxed, apply anesthetic ointment to the rectal zone and unlock them.
    • Body temperature: Maintain normal body temperature
  • During the beginning of the crisis, carrying out the Management Plan according to (NIC)
    • Dysreflexia management:
      • Administer intravenous antihypertensive drugs, as ordered by
      • Stay with the patient and control their condition every 3 to 5 minutes if hyperreflexia occurs
      • Place the head of the bed vertically, as appropriate, if hyperreflexia occurs