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.
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
- 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).
- Blurred vision.
- Chest pain.
- Metallic taste in the mouth.
- Nasal congestion.
- Difficult passage of feces
- Digital stimulation
- Fecal impaction
- Cutaneous stimulation
- Skin irritation
- Irritating stimuli below level of injury
- Painful stimuli below level of injury
- Pressure over bony prominence
- Pressure over genitalia
- Range of motion exercises
Regulatory -Situational Stimuli
- Constrictive clothing
- Environmental temperature fluctuations
- Bladder distention
- Bladder spasm
- Sexual intercourse
- Insufficient caregiver knowledge of disease process
- Insufficient knowledge of disease process
At risk population
- Extremes of environmental temperature
- Bowel distention
- Deep vein thrombosis
- Detrusor sphincter dyssynergia
- Esophageal reflux disease
- Gastric ulcer
- Gastrointestinal system pathology
- Heterotopic bone
- Labor and delivery period
- Ovarian cyst
- Pharmaceutical agent
- Pulmonary emboli
- Renal calculi
- Substance withdrawal
- Surgical procedure
- Urinary catheterization
- Urinary tract infection
- Status of vital signs.
- Neurological state.
- Neurological state: autonomous.
- 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.