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AUTONOMIC DYSREFLEXIA Nursing Care Plan

Autonomic Dysreflexia

Risk for Autonomic Dysreflexia
NANDA-I Definition
Life-threatening, uninhibited sympathetic response of the nervous
system to a noxious stimulus after a spinal cord injury at T7 or
above
Defining Characteristics
Major (Must Be Present)
The client with spinal cord injury (T6 or above) with:
Paroxysmal hypertension* (sudden periodic elevated blood pressure
in which systolic pressure is above 140 mm Hg
and diastolic
is above 90 mm Hg)
Bradycardia or tachycardia* (pulse rate less than 60 or more than
100 beats/min)
Diaphoresis (above the injury)*
Red splotches on skin (above the injury)*
Pallor (below the injury)*
Headache (a diffuse pain in different portions of the head and
not confined to any nerve distribution area)*
Apprehension
Dilated pupils
Minor (May Be Present)
Chilling
Conjunctival congestion
Horner’s syndrome* (pupillary contraction; partial ptosis of the
eyelid; enophthalmos; sometimes, loss of sweating over the
affected
side of the face)
Paresthesia

Related Factors
Pathophysiologic
Related to visceral stretching and irritation secondary to:
Gastrointestinal
Gastric distention
Constipation
Gastric ulceration
Fecal impaction
Hemorrhoids
Acute abdominal condition
Anal fissure
Urologic
Bladder distension* Urinary calculi Urinary tract infection
Skin Irritation*
Pressure ulcers
Insect bites
Burns
Ingrown toenails
Sunburn
Blister
Reproductive
Menstruation
Epididymitis
Pregnancy or delivery
Uterine contraction
Vaginal infection
Vaginal dilation
Related to fracture
Related to stimulation of skin (abdominal, thigh)
Related to spastic sphincter
Related to deep vein thrombosis
Related to pain
Treatment Related
Related to visceral stretching secondary to:
Removal of fecal impaction
Clogged or nonpatent catheter
Visceral stretching and irritation secondary to surgical incision,
enemas
Catheterization, enema

Situational (Personal, Environmental)
Related to deficient client knowledge* of prevention or treatment
Related to visceral stretching secondary to:
“Boosting” (Binding legs and distending bladder to boost norepinephrine
production; McClain et al., 1999).
Sexual activity
Menstruation
Pregnancy or delivery
Related to neural stimulation secondary to immersion in cold water

Author's Notes
Autonomic Dysreflexia represents a life-threatening situation that nurseprescribed
interventions can prevent or treat. Prevention involves
teaching the client to reduce sympathetic nervous system stimulation
and not using interventions that can cause such stimulation. Treatment
focuses on reducing or eliminating noxious stimuli (e.g., fecal impaction,
urinary retention). If nursing actions do not resolve symptoms, initiation
of medical intervention is critical. When a client requires medical treatment
for all or most episodes of dysreflexia, the situation can be labeled
a collaborative problem: RC of Dysreflexia.

Goal
The client/family will respond to early signs/symptoms. The client/
family will take action to prevent dysreflexia as evidenced by
the following indicators:
• State factors that cause dysreflexia.
• Describe the treatment for dysreflexia.
• Relate indications for emergency treatment.

Interventions
Assess for Causative or Contributing Factors
See Related Factors.
Proceed as Follows If Signs of Dysreflexia Occur
• Stand or sit the client up.
• Lower the client’s legs.
• Loosen all the client’s constrictive clothing or appliances.
Check for Distended Bladder
If the Client Is Catheterized:
• Check the catheter for kinks or compression.
• Irrigate the catheter with only 30 mL of saline, very slowly.
• Replace the catheter if it will not drain.
If the Client Is Not Catheterized:
• Insert the catheter using dibucaine hydrochloride ointment
(Nupercainal).
• Remove 500 mL, then clamp for 15 minutes.
• Repeat the cycle until the bladder is drained.
Check for Fecal Impaction
• First apply Nupercainal to the anus and into the rectum for
1 inch (2.54 cm).
• Gently check the rectum with a well-lubricated glove using
your index finger.
• Insert rectal suppository or gently remove impaction.
Check for Skin Irritation
• Spray the skin lesion that is triggering the dysreflexia with a
topical anesthetic agent.
• Remove support hose.
Continue to Monitor Blood Pressure Every 3 to 5 Minutes
Immediately Consult Physician for Pharmacologic Treatment If
Hypertension Is Double Baseline or Noxious Stimuli Are Unable
to Be Eliminated
Initiate Health Teaching and Referrals as Indicated
• Teach the signs, symptoms, and treatment of dysreflexia to the
client and family.
• Teach the indications that warrant immediate medical
intervention.
• Explain situations that trigger dysreflexia (menstrual cycle,
sexual activity, elimination).
• Teach the client to watch for early signs and to intervene
immediately.
• Teach the client to observe for early signs of bladder infections
and skin lesions (pressure ulcers, ingrown toenails).
• Advise consultation with a physician for long-term pharmacologic
management if the client is very vulnerable.
• Document the frequency of episodes and precipitating
factor(s).
• Provide printed instructions to guide actions during the crisis
or to show to other health care personnel (e.g., dentists, gynecologists;
Kavchak-Keyes, 2000).
• Advise athletes with high spinal cord injury about the danger
of boosting.
• Explain that failure to reverse dysreflexia can result in status
epilepticus, stroke, and death. However, avoidance of noxious
triggers can “prevent the episode entirely”

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