Domain 9. Coping-stress tolerance
Class 3. Neurobehavioral stress
Diagnostic Code: 00010
Nanda label: Risk for autonomic dysreflexia
Diagnostic focus: Autonomic dysreflexia
Nursing diagnosis risk for autonomic dysreflexia is a condition that occurs when the autonomic nervous system goes into overdrive, resulting in an exaggerated response to stimuli. This can range from mild symptoms to dangerous reactions, such as high blood pressure or seizures. It is important for healthcare professionals to recognize the signs and symptoms of autonomic dysreflexia so that early treatment can be provided. This article provides an in-depth look at the condition, including risk factors, associated conditions, nursing diagnosis criteria, and suggested interventions. It ends with a list of frequently asked questions about autonomic dysreflexia risk.
NANDA Nursing Diagnosis Definition
Autonomic dysreflexia (AD) is an autonomic nervous system reaction to an environmental stimulus. It is characterized by exaggerated changes in heart rate, breathing, and blood pressure due to stimulation of the parasympathetic and sympathetic systems. AD can be life threatening and should be treated with immediate medical attention.
There are a number of risk factors that can contribute to the development of autonomic dysreflexia. These include:
- Infection: Infections such as urinary tract infections can trigger AD.
- Trauma: Physical trauma to the spine or head can lead to overstimulation of the autonomic nervous system.
- Medications: Medications can sometimes stimulate the parasympathetic nervous system and lead to AD.
- Neurodegenerative Diseases: Neurodegenerative diseases such as Parkinson’s, Alzheimer’s, and Huntington’s can also trigger AD.
- Metabolic Disorders: Metabolic disorders such as diabetes and thyroid disease can also lead to AD.
- Brain Tumors: Brain tumors can interfere with the normal functioning of the autonomic nervous system and lead to AD.
- Neurological Disorders: Neurological disorders such as stroke, multiple sclerosis, and spinal cord injury can also contribute to the development of AD.
At Risk Population
Individuals who are most at risk for developing autonomic dysreflexia are those with chronic conditions or neurological impairments. People with spinal cord injuries, brain injuries, multiple sclerosis, and other neurologic diseases are especially vulnerable. Individuals with metabolic disorders, like diabetes, and medications known to increase the risk for the condition are also more likely to develop AD.
Autonomic dysreflexia can be accompanied by a number of other related conditions, including:
- High Blood Pressure: AD can result in sudden increases in blood pressure, putting the patient at increased risk for stroke and heart attack.
- Seizures: Seizures can result if blood pressure is not controlled quickly.
- Anxiety: The onset of AD can cause patients to feel anxious and overwhelmed.
- Fatigue: The overstimulation of the nervous system can lead to exhaustion.
- Depression: High levels of stress can cause depression.
Suggestions of Use
Nursing diagnosis risk for autonomic dysreflexia is particularly important for healthcare professionals to consider when examining patients with certain preconditions and risk factors. Early recognition and proper treatment can reduce the risk of long-term health complications. Healthcare professionals should also be aware of the risk factors associated with AD and take appropriate steps to minimize them.
Suggested Alternative NANDA Nursing Diagnosis
In some cases, it may be necessary to consider alternate NANDA nursing diagnosis. These include:
- Activity Intolerance: This diagnosis refers to difficulty performing or tolerating activities due to fatigue and physical discomfort.
- Anxiety: This diagnosis refers to a state of heightened anxiety, fear, and worry.
- Fatigue: This diagnosis refers to a state of prolonged physical or mental exhaustion that interferes with the ability to perform normal daily activities.
- Pain: This diagnosis refers to an unpleasant sensation that is normally associated with tissue damage or injury, and can vary in intensity.
- Risk for Injury: This diagnosis indicates an increased likelihood that an individual may experience an injury or harm due to inadequate protection.
When assessing a patient for AD, it is important to collect information about their medical history, current medications, and any recent changes in their lifestyle. It is also important to observe the patient’s responses to various stimuli, such as taking blood pressure and noting any changes in heart rate. Additionally, it is important to note any complaints of pain, anxiety, or fatigue. All of this information should be taken into account when diagnosing and treating AD.
The following NOC Outcomes can be used when assessing and monitoring Autonomic Dysreflexia:
- Cardiac Output:Ability to monitor and maintain a safe cardiac output.
- Electrolyte and Acid-Base Balance: Ability to regulate electrolytes and acid-base balance.
- Respiratory Status:Ability to vigilantly monitor and regulate respiratory status.
- Thermoregulation:Ability to regulate body temperature.
- Cognitive Ability:Ability to identify and recall autonomic dysreflexia signs and symptoms.
- Pain Management:Ability to manage pain associated with the condition.
- Health Maintenance:Ability to modify lifestyle practices to reduce the risk of developing autonomic dysreflexia.
Evaluation Objectives and Criteria
When evaluating a patient for autonomic dysreflexia risk, healthcare professionals should consider:
- Physiological Symptoms: Signs of autonomic dysreflexia, such as increased heart rate, elevated blood pressure, and sweating.
- Underlying Causes: The presence of underlying causes, such as infection, trauma, or metabolic disorder.
- Level of Alertness: The ability of the patient to remain alert.
- Knowledge Acquisition: The patient’s knowledge of the condition and its treatment.
- Risk Reduction: The ability of the patient to reduce their risk of developing autonomic dysreflexia.
The following NIC Interventions can be used when evaluating and treating Autonomic Dysreflexia:
- Pharmacological Management: Administering medications to control blood pressure, heart rate, and breathing.
- Monitor Vital Signs: Monitoring and recording pulse, respiration, and blood pressure.
- Activity Modification: Increasing physical activity as tolerated, while decreasing or avoiding activities that could aggravate the symptoms of autonomic dysreflexia.
- Pain Management: Managing concurrent pain if it is present.
- Nutrition Therapy: Assessing nutritional needs of the patient and providing appropriate nutrition therapy.
- Environmental Management: Reducing environmental irritants that can trigger a reaction.
- Patient Education: Developing and delivering patient education specific to autonomic dysreflexia.
Nursing Activities for Autonomic Dysreflexia
To effectively manage autonomic dysreflexia, nurses should take the following actions:
- Monitor vital signs closely and provide appropriate medications to control elevated blood pressure or heart rate.
- Assess, monitor, and document any pain or other abnormal sensations the patient may be experiencing.
- Encourage the patient to increase physical activity as tolerated and decrease or avoid activities that may trigger autonomic dysreflexia.
- Educate the patient on lifestyle and prevention strategies that can help reduce the risk of autonomic dysreflexia.
- Provide resources and support to help the patient manage his/her condition.
Autonomic dysreflexia is a serious and potentially life-threatening condition that requires prompt and effective management. Recognizing the signs and symptoms and understanding the risk factors are essential for proper diagnosis and management. Nurses play a key role in educating patients, monitoring signs and symptoms, and providing appropriate intervention.
- What is autonomic dysreflexia? Autonomic dysreflexia is an exaggerated reaction of the autonomic nervous system to an environmental stimulus. It can range from mild symptoms to dangerous reactions, such as high blood pressure or seizures.
- What are the risk factors for autonomic dysreflexia? Risk factors for autonomic dysreflexia include infection, trauma, medications, neurodegenerative diseases, metabolic disorders, brain tumors, and neurological disorders.
- What should I do if I think I am at risk for autonomic dysreflexia? If you are at risk for developing autonomic dysreflexia, it is important to contact your healthcare provider immediately. Early recognition and treatment of autonomic dysreflexia can reduce the risk of dangerous health complications.
- What should I expect during an evaluation for autonomic dysreflexia? During an evaluation for autonomic dysreflexia, healthcare professionals will consider physiological symptoms, as well as underlying causes, level of alertness, knowledge acquisition, and risk reduction strategies.
- What are some nursing activities for autonomic dysreflexia? Nursing activities for autonomic dysreflexia include monitoring vital signs, activity modification, pain management, nutrition therapy, environmental management, and patient education.