00010 Risk for autonomic dysreflexia

Domain 9: coping/stress tolerance
Class 3: neurocomported stress
Diagnostic Code: 00010
Nanda label: risk of autonomous dysreflexia
Diagnostic focus: Autonomous dysreflexia
Approved 1998 • Revised 2000, 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of autonomous dysreflexia »  is defined as: susceptible to having an un inhibited response, threatening for life, of the sympathetic nervous system after a medullary shock in a person with a person with An alteration or injury to the spinal cord at the level of the sixth dorsal vertebra (D6) or higher (it has been demonstrated in patients with injuries in the seventh dorsal vertebra [D7] and the eighth dorsal vertebra [D8]), which can compromise the Health.

Risk 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 with spinal cord injury or injury 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

  • See use suggestions for autonomous dysreflexia.

Suggested alternative diagnostics

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

NOC Results

  • Risk detection: personal actions to identify threats to your own health
  • Intestinal elimination: Formation and evacuation of feces
  • Urinary elimination: Collection and discharge of urine
  • Cardiopulmonary state: adequacy of the blood volume expelled from the ventricles and exchange of carbon dioxide and oxygen at the alveolar level
  • Neurological state: Autonomous: Autonomic nervous system capacity to coordinate visceral and homeostatic function
  • Gastrointestinal function: process in which food (ingested or administered by probe) goes from ingestion to excretion

Evaluation objectives and criteria

  • The patient does not experience autonomous dysreflexia, as demonstrated by the cardiopulmonary state and the neurological state: autonomous, within the expected range for the individual
  • The patient demonstrates a neurological state: satisfactory autonomous, as manifested by the following indicators (specify from 1 to 5: severely, importantly, moderately, slightly or not compromised):
    • Effectiveness of cardiac pumping
    • Vasodilation and vasoconstriction response
    • Sweating response guideline
    • Intestinal mobility
    • Pupil reactivity
    • Peripheral tissue perfusion
  • The patient demonstrates a neurological state: satisfactory autonomous, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or none):
    • Broncoospasmos
    • Bladder spasms
    • Dilated or contracted pupils
    • Dysreflexia

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 habits
  • Identify the early signs and symptoms of dysreflexia (headache, blurred vision or parstesthesia)

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
  • Intestinal elimination management: establishment and maintenance of a regular habit of fecal evacuation
  • Urinary elimination management: maintenance of an optimal urinary excretion pattern
  • Pressure management: reduce the pressure in different areas of the body as much as possible
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
  • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications
  • Neurological surveillance: Patient data collection and analysis to prevent or reduce neurological complications

Nursing Activities

Valuations

  • See the assessments for autonomous dysreflexia.

Patient and family education

  • See patient and family education, for autonomous dysreflexia.

Others

  • Speed ??any harmful stimulus in the following order to prevent autonomous dysreflexia:
    • Bladder: Check the permeability of the probe or place probe to the patient
    • Intestines: if you are relaxed, apply anesthetic ointment to the rectal zone and unlock them; Consider an enema or a tube for flatness
    • Body temperature: Maintain a normal body temperature