Mrs. Rufino is a 38
years old office worker who had an accident that changed her life miserably.
She lost her job. Her son forced to live in his grandmother. Her grandfather's
wealth keep draining because of his hospital bill and medications. Mrs. Rufino
is badly injured that she can't even move her body. This is a nursing care
plan sample about autonomic dysreflexia of Mrs. Rufino, 38 years old, office
worker.
Assessment:
Objectives:
- The client with spinal
cord injury on T7
- Paroxysmal
hypertension, sudden periodic elevated blood pressure in which her systolic
pressure is above 160 mm Hg and diastolic is above 110 mm Hg
- Bradycardia 52 beats/min
- Diaphoresis above the injury site
- Red splotches on skin just above the injury site
- Headache
- Dilated pupils
- Chilling
- Constipated
- Distended stomach
Diagnosis:
Autonomic dysreflexia
related to visceral stretching and irritation secondary to gastric
distention and constipation.
Planning:
After 4 hours of nursing
intervention, the patient and family will respond to early signs/symptoms. The
patient and family will take action to prevent dysreflexia. The
patient and family can state factors that cause dysreflexia. The patient
and family can describe the treatment for dysreflexia. The patient and
family can relate indications for emergency treatment.
Interventions:
- Assess for causative
or contributing factors on Mrs. Rufino's problem.
- Stand or sit Mrs. Rufino. Lower her legs. Loosen all her
constrictive clothing or accessories.
- Check for distended bladder. If Mrs. Rufino is in catheter, check
her catheter for kinks or compression. Irrigate the catheter with only 30 mL of
saline, very slowly. Replace her catheter if it will not drain. If
Mrs. Rufino Is not catheterized, insert her catheter using dibucaine
hydrochloride ointment. Remove 500 mL, then clamp for 15 minutes. Repeat the
cycle until her bladder is drained.
- Check for fecal impaction. First apply Nupercainal to Mrs. Rufino's anus and
into her rectum for 1 inch (2.54 cm). Gently check her 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 Mrs. Rufino's blood pressure every 3 to 5
minutes. Immediately consult her physician for pharmacologic treatment of hypertension
Is double baseline.
- Initiate health
teaching and referrals as indicated. Teach Mrs. Rufino the signs,
symptoms, and treatment of dysreflexia to her and her family. Teach her
the indications that warrant immediate medical intervention. Explain
to her the situations that trigger dysreflexia. Teach Mrs. Rufino to
watch for early signs and to intervene immediately. Teach Mrs.
Rufino to observe for early signs of bladder infections and skin
lesions.
- Advise consultation with a physician for long-term pharmacologic management
if Mrs. Rufino is very vulnerable.
- Document the frequency of episodes and precipitating factors. Provide printed
instructions to guide actions during the crisis or to show to other health care
personnel.
- Explain that failure to reverse dysreflexia can result in status epilepticus,
stroke, and death. However, avoidance of noxious triggers can “prevent the
episode entirely.”
Evaluation:
After 4 hours of nursing
intervention, the patient and family were responded to early signs/symptoms.
The patient and family were taken action to prevent dysreflexia. The
patient and family stated factors that cause dysreflexia. The patient and
family described the treatment for dysreflexia. The patient and family
related indications for emergency treatment.
For more samples of
nursing care plan you are free to check it out in our NCP LIST page.
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