00009 Autonomic dysreflexia

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00009 Autonomic dysreflexia

Definition of the NANDA label

Autonomic dysreflexia is the state in which a person with a spinal cord injury at the level of D7 or higher, when faced with a causal stimulus, experiences a disinhibition of the sympathetic nervous system that endangers your life.

Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury at the 7th thoracic vertebra (T7) or above.

Defining characteristics

Individual with spinal cord injury at the level of D7 or higher with:

  • Paroxysmal hypertension (sudden periodic rises in blood pressure, with rises in systolic pressure above 140 mmHg and rises in diastolic pressure above
    90 mmHg).
  • Bradycardia (pulse less than 60 / min) or tachycardia (pulse greater than 100 / min).
  • Diaphoresis (above the lesion).
  • Red spots on the skin (above the lesion).
    Paleness (below the lesion).
  • Diffuse headache and not limited to any specific area of ​​innervation.
  • Chills and chills.
  • Conjunctival congestion.
  • Horner’s syndrome, due to cervical sympathetic paralysis (miosis, partial palpebral ptosis, enophthalmia and possible loss of sweating on the affected side of the face).
  • Paresthesias (increased sensitivity, tingling, numbness or itching).
  • Piloerection.
  • Blurred vision.
  • Chest pain.
  • Metallic taste in the mouth.
  • Nasal congestion.

Related factors

Gastrointestinal Stimuli

  • Constipation
  • Difficult passage of feces
  • Digital stimulation
  • Enemas
  • Fecal impaction
  • Suppositories

Integumentary Stimuli

  • Cutaneous stimulation
  • Skin irritation

Musculoskeletal-Neurological Stimuli

  • Irritating stimuli below level of injury
  • Painful stimuli below level of injury
  • Pressure over bony prominence
  • Pressure over genitalia
  • Range of motion exercises
  • Spasm

Regulatory -Situational Stimuli

  • Constrictive clothing
  • Environmental temperature fluctuations
  • Positioning

Reproductive-Urological Stimuli

  • Bladder distention
  • Bladder spasm
  • Instrumentation
  • Sexual intercourse

Other

  • Insufficient caregiver knowledge of disease process
  • Insufficient knowledge of disease process

At risk population

  • Ejaculation
  • Extremes of environmental temperature
  • Menstruation

Associated condition

  • Bowel distention
  • Cystitis
  • Deep vein thrombosis
  • Detrusor sphincter dyssynergia
  • Epididymitis
  • Esophageal reflux disease
  • Fracture
  • Gallstones
  • Gastric ulcer
  • Gastrointestinal system pathology
  • Hemorrhoids
  • Heterotopic bone
  • Labor and delivery period
  • Ovarian cyst
  • Pharmaceutical agent
  • Pregnancy
  • Pulmonary emboli
  • Renal calculi
  • Substance withdrawal
  • Sunburn
  • Surgical procedure
  • Urethritis
  • Urinary catheterization
  • Urinary tract infection
  • Wound

NOC

  • Status of vital signs.
  • Neurological state.
  • Neurological state: autonomous.

NIC

  • Vital signs monitoring.
  • Management of dysreflexia.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is
completed to bring it up to a level of evidence 2.1 or higher.

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