AUTONOMIC DYSREFLEXIA Nursing Care Plan

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 if 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.

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