Introduction to Nursing Care Plan for Autonomic Dysreflexia
Autonomic dysreflexia (AD) is a life-threatening condition in patients with a spinal cord injury at levels of T6 and above. It is an exaggerated, uncontrolled sympathetic reflex wherein the blood pressure increases rapidly upon stimulation of the lower body. AD can cause potentially serious consequences and should be managed immediately and effectively.
Assessment
Signs and Symptoms of Autonomic Dysreflexia include:
- Rapid increase of systolic BP, usually greater than 180-200mmHG
- Cerebral vascular accidents like headaches, visual disturbances, dizziness, nausea and vomiting
- Flushing of face and neck
- Sweating profusely
- Goose bumps
- Stuffy nose, clammy hands, bradycardia, nasal secretion
- Hypersensitivity to skin stimulation and/or external stimulus
Nursing Diagnosis
Risk for Autonomic Dysreflexia secondary to traumatic or untreatable damage of the spinal cord such as:
- Spinal cord lesion
- Surgical repairing of a lesion
- Stretching of nerve root
- Obstruction of urinary tract
- Infections of bladder or kidney
Outcomes
The patient will demonstrate:
- An understanding of the signs and symptoms of autonmic dysreflexia
- An increased awareness in self-care and environmental safety measures
- Recognition of precipitating factors
- Use of strategies to reduce risk of recurrence
- Stable and optimal biopsychosocial functions
- Minimized episodes of autonomic dysreflexia
Interventions
The nurse will provide:
- Assessment for precipitating factors associated with autonomic dysreflexia
- Education on warning signs of autonomic dysreflexia, its treatment and management
- Instructions for self-care activities aimed at prevention
- Monitoring of vital signs
- Maintenance of optimum environmental conditions
- Medication administration and monitoring blood pressure
Rationales
Evaluating the precipitating factors will allow the nurse to develop strategies to reduce the risk of recurrence. Education on warning signs will also give the patient a better understanding of how to avoid further episodes. Monitorign vitals and maintaining optimum environmental conditions is essential in preventing autonomic dysreflexia. The medication helps to bring normal blood pressure and other symptoms. Nursing interventions are very important to manage AD.
Evaluation
At the end of the care plan, the patient will be able to demonstrate appropriate self-care measures, prevention strategies, and minimized episodes of autonomic dysreflexia.
Conclusion
Autonomic dysreflexia is a life-threatening condition which can be prevented by appropriate nursing interventions. Early diagnosis and treatment can reduce the risk of long-term complications. Appropriate nursing care plans, assessments, interventions, and evaluations are essential to achieve safety, optimal functioning and improved quality of life.
FAQs
- What is autonomic dysreflexia?
Autonomic dysreflexia is an exaggerated, uncontrolled sympathetic reflex wherein the blood pressure increases rapidly upon stimulation of the lower body. - What causes autonomic dysreflexia?
Autonomic dysreflexia usually occurs in patients with a spinal cord injury at levels of T6 and higher. Other causes include traumatic or untreatable damage of the spinal cord, stretching of nerve root, obstruction of urinary tract, and infections of bladder or kidney. - What are the signs and symptoms of autonomic dysreflexia?
Signs and symptoms of autonomic dysreflexia include rapid increase of systolic blood pressure, headaches, visual disturbances, dizziness, nausea and vomiting, flushing of face and neck, sweating profusely, goose bumps, and hypersensitivity to skin stimulation and/or external stimulus. - What are the interventions for autonomic dysreflexia?
Interventions for autonomic dysreflexia include assessment for precipitating factors, education on warning signs, instructions for self-care activities, monitoring of vital signs, maintenance of optimum environmental conditions, medication administration, and monitoring of blood pressure. - What is the goal of autonomic dysreflexia nursing care plan?
The goal of autonomic dysreflexia nursing care plan is to minimize episodes of autonomic dysreflexia, increase awareness in self-care and environmental safety measures, recognize precipitating factors, and use strategies to reduce risk of recurrence and achieve stable and optimal biopsychosocial functions.
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