Autonomic Dysreflexia Nursing Diagnosis and Nursing Care Plan

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Autonomic Dysreflexia Nursing Care Plans Diagnosis and Interventions

Autonomic Dysreflexia NCLEX Review and Nursing Care Plans

Autonomic dysreflexia (AD) is a medical condition that involves the overreaction of the autonomic nervous system (ANS) to stimulation usually due to spinal cord injury.

The ANS is a part of the peripheral nervous system. It is the regulator of the involuntary processes in the body, such as respiration, heart rate, blood pressure, digestion, and intimate arousal.

When AD occurs due to the stimulation below the damaged spinal cord, the bodily processes related to ANS can be affected. Due to its potential severe complications to breath and circulation, AD is considered an emergency that requires immediate medical intervention.

Signs and Symptoms of Autonomic Dysreflexia

  • Pounding headache
  • Feeling flushed
  • Bradycardia – slow heart rate
  • High blood pressure
  • Trouble breathing
  • Heavy sweating
  • Dilated pupils
  • Blurry vision
  • Blotching above the level of injury
  • Goosebumps below the level of injury
  • Nasal congestion

Causes and Risk Factors of Autonomic Dysreflexia

AD may result from spinal injuries that involve the area from the shoulder blades or above. The body parts below the damaged spinal injuries may feel numb, and the patient is rendered unable to control the muscles in these areas.

However, the nerves still attempt to send signals back to the brain, causing an abnormal reaction (dysreflexia or hyperreflexia) to stimuli. Other causes and risk factors for autonomic dysreflexia include:

  • Overfull bladder or bladder distention
  • Urinary tract infections (UTIs)
  • Overfull bowel or bowel distention
  • Constipation
  • Gastrointestinal disorders such as gastritis, stomach ulcers, and gallstones
  • Sexual activity
  • Trauma – broken bones or other injuries
  • Extreme temperatures or sudden changes in temperature
  • Tight clothing or devices
  • Ingrown toenails

Complications of Autonomic Dysreflexia

  1. Stroke, Faulty signals to the autonomic nervous system may cause the blood vessels to constrict and become narrower. This can result to an elevation of blood pressure, which may put the patient at high risk for stroke or heart attack.
  2. Cardiac arrest
  3. Seizure

Diagnosis of Autonomic Dysreflexia

  • Physical assessment and health history – to check for severe headache, signs of spinal cord injury, and other signs and symptoms of autonomic dysreflexia
  • Imaging – X-rays and ultrasound may be ordered by the physician to help with confirming the diagnosis
  • Laboratory tests – may include blood biochemistry tests to evaluate kidney function, and urine tests to check for the presence of infection (particularly UTIs)

Treatment for Autonomic Dysreflexia

  1. Insertion of an indwelling catheter. The nurse or physician should insert an indwelling catheter if one isn’t already in place to alleviate or prevent bladder distension. Encourage the patient to follow the bladder management program. Refer the patient to the urology team as required.
  2. Monitoring. The following interventions are recommended in the care of a patient with AD:
  3. Proper positioning – the patient should be placed on an upright sitting position to lower the blood pressure level. The nurse should ask and check for tight clothing.
  4. Blood Pressure Control – the blood pressure should be monitored every 5 minutes until the level returns to normal. Immediate administration of blood pressure-lowering medications otherwise known as antihypertensives should be done if the systolic BP is higher than 150 mmHg.
  5. Input and Output Monitoring – the nurse should monitor the input and output, as well as establish a daily stool chart. It is also important to record of constipation, presence of hemorrhoids, bladder distension, or any kinks/obstructions to the indwelling catheter.  Empty the bladder by regularly draining the catheter.

Prevention of Autonomic Dysreflexia

  • Regularly use the bathroom to avoid an overfull bladder or bowels.
  • Always check for any ingrown toenails.
  • Seek immediate medical help if there is any sign of urinary tract infection.

Nursing Care Plans for of Autonomic Dysreflexia

Nursing Care Plan for Autonomic Dysreflexia 1

Nursing Diagnosis: Risk for Seizure related to loss of muscular control secondary to autonomic dysreflexia

Desired Outcome: The patient will be able to prevent injury by means of maintaining his/her treatment regimen.

Autonomic Dysreflexia Nursing InterventionsRationales
Educate the patient and caregiver on how to identify the warning signs of an impending seizure.To empower the patient and his/her caregiver to recognize a seizure activity, and help protect the patient from any injury or trauma. To reduce the feeling of helplessness on both the patient and the caregiver.  
Place the bed in the lowest position. Put pads on the bed rails and the floor.To prevent or minimize injury in a patient during a seizure.
Advise the caregiver to stay with the patient during and after the seizure.To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.
Administer prescribed medications such as benzodiazepines, anticonvulsants, anti-epileptics, and other anti-seizure drugs.To control the occurrence of seizures.
During seizure, turn the patient’s head to the side, and suction the airway if needed.        Use a plastic bite block only when the jaw is relaxed.To maintain a patent airway.     Avoid inserting the plastic bite block when the teeth are clenched to prevent any dental damage. Do not use wooden tongue depressors as they can break or splinter, causing oral damage.  

Nursing Care Plan for Autonomic Dysreflexia 2

Nursing Diagnosis: Deficient Knowledge related to autonomic dysreflexia as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of autonomic dysreflexia and its management.

Autonomic Dysreflexia Nursing InterventionsRationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g., decreased cognitive ability).To address the patient’s cognition and mental status towards the new diagnosis of AD and to help the patient overcome blocks to learning.
Explain what autonomic dysreflexia is and related signs and symptoms. Avoid using medical jargons and explain in layman’s terms.To provide information on the disease and its pathophysiology in the simplest way possible.
Educate the patient about safety measures related to possible seizure activity, stroke, or cardiac arrest. Create a plan for Activities of Daily Living (ADLs) with the patient and the caregiver, especially including important activities such as driving, operating machinery, swimming, and bathing.To encourage the patient to live his/her daily life optimally, while ensuring that he/she is safe from injury if a seizure occurs.
Inform the patient the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) to manage autonomic dysreflexia. Ask the patient to repeat or demonstrate the self-administration details to you.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Encourage the patient to wear his/her medical bracelet at all times to indicate that he/she has a autonomic dysreflexia and is at high risk for seizure, cardiac arrest, or stroke.To enable the patient to receive an expedited care during an emergency situation.

Nursing Care Plan for Autonomic Dysreflexia 3

Nursing Diagnosis: Risk for Fall related to loss of sensory coordination and muscular control secondary to autonomic dysreflexia

Desired Outcome: The patient will be able to prevent fall by means of maintaining his/her treatment regimen in order to eliminate seizure activity.

Autonomic Dysreflexia Nursing InterventionsRationale
Explore any history of seizure and enable the patient and caregiver to identify the warning signs of an impending seizure.To empower the patient and his/her caregiver to recognize a seizure activity, and help protect the patient from any injury or trauma. To reduce the feeling of helplessness on both the patient and the caregiver.  
Create a seizure chart, a falls risk assessment, and a bed rails assessment.To effectively assess and monitor the patient’s seizure activity and falls risk, as well as the need to use bed rails.
Place the bed in the lowest position. Put pads on the bed rails and the floor.To prevent or minimize injury in a patient during a seizure.
Advise the caregiver to stay with the patient during and after the seizure.To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.
Place the call bell within patient’s reach. Advise the patient to ask for help when mobilizing.Immediate administration of blood pressure-lowering medications otherwise known as antihypertensives should be done if the systolic BP is higher than 150 mmHg. This puts the patient at risk for sudden hypotension, which in turn can result to a fall if the patient is left unattended.  
During seizure, turn the patient’s head to the side, and suction the airway if needed. Do not leave the patient. Ask for another member of staff for help as needed.To maintain a patent airway and to promote patient’s safety during seizure.      

Nursing Care Plan for Autonomic Dysreflexia 4

Nursing Diagnosis: Risk for infection related to catheterization

Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear urine.

Autonomic Dysreflexia Nursing InterventionsRationales
Insert an indwelling catheter using aseptic non-touch technique (ANTT).To prevent infection.
Assess, monitor, and record the patient’s vital signs.Vital signs monitoring particularly the patient’s temperature help in the monitoring of possible infections.   
Regularly assess the insertion site and surrounding skin for color, exudates, erythema, and crusting lesions.The friction between the tube and skin can irritate the insertion site and surrounding skin making it a suitable site for infection.  
Palpate the bladder and observe for bladder distention. Use a bladder scanner as required.To check for bladder distention and bladder retention in order to determine the continuous need for the catheter. The catheter may be removed if bladder distention is resolved.
Empty the catheter bag at least once every 4 hours.To avoid urine accumulation which may cause bacteria to breed and infection to start subsequently.
Observe proper hand hygiene and wear gloves when draining the catheter bag.To prevent infection.

More Autonomic Dysreflexia Nursing Diagnosis

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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