00010 Risk for autonomic dysreflexia

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00010 Risk for autonomic dysreflexia

Definition of the NANDA label

The Risk of Autonomic Dysreflexia is the state in which a person with spinal cord injury or disease at the level of D6 or higher, after spinal shock, runs the risk of disinhibition of the nervous system. nice that endangers his life.

Susceptible to life-threatening, uninhibited response of the sympathetic nervous system post-spinal shock, in an individual with spinal cord injury or lesion at the 6th thoracic vertebra (T6) or above (has been demonstrated in patients with injuries at the 7th thoracic vertebra [T7] and the 8th thoracic vertebra [T8]), which may compromise health.

Risk factors

  • Injury or alteration in D6 or higher and at least one of the following STIMULES causal:

1) neurological:

  • Painful or irritating stimuli below the level of injury.

2) urological:

  • Bladder distention.
  • Dysynergia of the detrusor sphincter.
  • Bladder spasm.
  • Use of instruments or surgery.
  • Epididymitis.
  • Urethritis.
  • Urinary tract infection.
  • Calculations.
  • Cystitis.
  • Catheterization.

3) gastrointestinal:

  • Intestinal bloating.
  • Fecal impaction.
  • Digital stimulation.
  • Suppositories.
  • Hemorrhoids.
  • Difficulty defecation.
  • Constipation.
  • Enemas.
  • Pathology of the gastrointestinal system.
  • Gastric ulcer.
  • Esophageal reflux.
  • Gallstones.

4) of the reproductive system:

  • Menstruation.
  • Intercourse.
  • Pregnancy.
  • Labor and delivery.
  • Ovarian cyst.
  • Ejaculation.

5) cutaneous and musculoskeletal:

  • Skin stimulation (eg, pressure ulcer, ingrown toenail, dressings, burns, rashes).
  • Pressure on bony prominences or genitalia.
  • Bone heterotrophy.
  • Spasms.
  • Fractures.
  • Range of motion exercises.
  • Wounds.
  • Sunburn.

6) of the regulatory system:

  • Temperature fluctuation.
  • Extreme ambient temperatures.

7) situational:

  • Position.
  • Constrictive clothing (eg, belt, socks).
  • Drug reactions (eg, sympathomimetic decongestants, vasoconstrictors, narcotic withdrawal).
  • Surgical procedures.

Cardiopulmonary problems:

  • Pulmonary embolism.
  • Deep vein thrombosis.

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.
  • Autonomous neurological state.
  • Severity of the symptom.

NIC

  • Vital signs monitoring.
  • Management of dysreflexia.
  • Neurological monitoring.

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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