Autonomic dysreflexia

Autonomic dysreflexia

Domain 9. Coping-stress tolerance
Class 3. Neurobehavioral stress
Diagnostic Code: 00009
Nanda label: Autonomic dysreflexia
Diagnostic focus: Autonomic dysreflexia

Autonomic dysreflexia (AD) is a potentially life-threatening condition that can occur in people with spinal cord injuries at the level of T6 or above. This nursing diagnosis refers to the abnormal response of the autonomic nervous system to stimuli that are harmless or even below the injury level. In this article, we will explore the NANDA Nursing Diagnosis Definition, defining characteristics, related factors, at-risk population, associated conditions, suggestions for use, and alternative Nanda diagnoses. We will also discuss the NOC outcomes, evaluation objectives and criteria, and NIC interventions for managing Autonomic dysreflexia.

NANDA Nursing Diagnosis Definition

Autonomic Dysreflexia is defined as an abnormal, life-threatening response of the autonomic nervous system to stimuli that are harmless or even below the level of the spinal cord injury. It is characterized by a sudden and significant increase in blood pressure, which can lead to severe complications such as seizures, strokes, and even death.

Defining Characteristics

The defining characteristics of Autonomic dysreflexia include sudden, severe hypertension, headache, sweating above the level of injury, bradycardia, piloerection, flushing, and blurred vision.

Related Factors

There are several factors that can trigger Autonomic dysreflexia, including bladder or bowel distention, urinary tract infections, pressure ulcers, skin irritation or injury, ingrown toenails, and other painful stimuli.

At-risk Population

Individuals with spinal cord injuries at or above the T6 level are at the greatest risk of developing Autonomic dysreflexia. Additionally, patients with spina bifida or other neurological conditions may also be at risk.

Associated Conditions

Autonomic dysreflexia can lead to severe complications such as seizures, strokes, and even death. Therefore, prompt recognition and management of the condition are essential.

Suggestions for Use

To manage Autonomic dysreflexia, nurses should identify and remove the triggering stimuli as soon as possible. They should also elevate the head of the bed to reduce blood pressure and administer medications as prescribed.

Suggested Alternative Nanda Diagnoses

Alternative Nanda diagnoses that may be appropriate for Autonomic dysreflexia include Risk for Injury related to sudden elevation of blood pressure and Impaired Physical Mobility related to spinal cord injury.

NOC Outcomes

NOC outcomes that may be appropriate for Autonomic dysreflexia include Blood Pressure, Cardiac Output, Skin Integrity, and Tissue Perfusion.

Evaluation Objectives and Criteria

The evaluation objectives and criteria for Autonomic dysreflexia include monitoring and managing blood pressure, assessing skin integrity, and evaluating the effectiveness of interventions in preventing recurrence of the condition.

NIC Interventions

The NIC interventions for Autonomic dysreflexia include assessing for potential triggers, monitoring vital signs, elevating the head of the bed, administering medications as prescribed, and providing education to prevent recurrence of the condition.

Nursing Activities

Nursing activities for Autonomic dysreflexia include monitoring vital signs, assessing for potential triggers, providing education to patients and families, and administering medications as prescribed.

Conclusion

Autonomic dysreflexia is a life-threatening condition that requires prompt recognition and management. Nurses play a critical role in identifying potential triggers, monitoring vital signs, and administering appropriate interventions to prevent recurrence of the condition.

FAQs

  1. What is Autonomic dysreflexia?
    Autonomic dysreflexia is a potentially life-threatening condition that can occur in people with spinal cord injuries at or above the T6 level. It is characterized by a sudden and significant increase in blood pressure, which can lead to severe complications such as seizures, strokes, and even death.
  2. What are the symptoms of Autonomic dysreflexia?
    The symptoms of Autonomic dysreflexia include a sudden increase in blood pressure, severe headache, flushing or redness of the face, sweating above the level of the injury, stuffy nose, nausea, blurred vision, and a slow heart rate.
  3. What are the common triggers of Autonomic dysreflexia?
    Some of the common triggers of Autonomic dysreflexia include bladder distention or irritation, bowel distention or impaction, skin irritation or pressure ulcers, tight clothing or shoes, and sexual activity.
  4. How is Autonomic dysreflexia managed?
    To manage Autonomic dysreflexia, it is important to identify and remove the triggering factors. This may include catheterization or medication to relieve bladder or bowel distention, changing position or removing tight clothing, and treating skin irritation or pressure ulcers. In severe cases, medication may be needed to lower blood pressure.
  5. What are some NOC outcomes for Autonomic dysreflexia?
    Some NOC outcomes that may be appropriate for patients with Autonomic dysreflexia include Blood Pressure, Neurological Status, Pain Control, Tissue Perfusion, and Urinary Continence.