Nursing Dx

Taxonomy II: Coping/Stress Tolerance—Class 3
Neurobehavioral Stress (00009)
[Diagnostic Division: Circulation]
Submitted 1988

Definition: Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury [SCI] at T7 or above

Bladder or bowel distention; [catheter insertion, obstruction, irrigation]
Skin irritation

Lack of client and caregiver knowledge
[Sexual excitation]
[Environmental temperature extremes]

Defining Characteristics
SUBJECTIVE
Headache (a diffuse pain in different portions of the head and not confined to any nerve distribution area) Paresthesia, chilling, blurred vision, chest pain, metallic taste in mouth, nasal congestion
OBJECTIVE
Paroxysmal hypertension (sudden periodic elevated blood pressure in which systolic pressure >140 mm Hg and diastolic >90 mm Hg)
Bradycardia or tachycardia (heart rate <60 or >100 beats per minute, respectively)
Diaphoresis (above the injury), red splotches on skin (above the injury), pallor (below the injury)
Horner’s syndrome (contraction of the pupil, partial ptosis of the eyelid, enophthalmos and sometimes loss of sweating over the affected side of the face); conjunctival congestion Pilomotor reflex (gooseflesh formation when skin is cooled)

Desired Outcomes/Evaluation
Criteria—Client/Caregiver Will:
• Identify risk factors.
• Recognize signs/symptoms of syndrome.
• Demonstrate corrective techniques.
• Experience no episodes of dysreflexia or will seek medical intervention in a timely manner.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess precipitating risk factors:
• Monitor for bladder distention, presence of bladder spasms/ stones or infection.
• Assess for bowel distention, fecal impaction, problems with bowel management program.
• Observe skin/tissue pressure areas, especially following prolonged sitting.
• Remove client from and/or instruct to avoid environmental temperature extremes/drafts.
• Monitor closely during procedures/diagnostics that manipulate bladder or bowel.

NURSING PRIORITY NO. 2. To provide for early detection and immediate intervention:
• Investigate associated complaints/symptoms (e.g., severe headache, chest pains, blurred vision, facial flushing, nausea, metallic taste, Horner’s syndrome).
• Correct/eliminate causative stimulus (e.g., distended bladder/ bowel, skin pressure/irritation, temperature extremes).
• Elevate head of bed to 45-degree angle or place in sitting position to lower blood pressure.
• Monitor vital signs frequently during acute episode. Continue to monitor blood pressure at intervals after symptoms subside to evaluate effectiveness of interventions.
• Administer medications as required to block excessive autonomic nerve transmission, normalize heart rate, and reduce hypertension.
• Carefully adjust dosage of antihypertensive medications for children, the elderly, or pregnant women. (Assists in preventing seizures and maintaining blood pressure within desired range.)
• Apply local anesthetic ointment to rectum; remove impaction after symptoms subside to remove causative problem without causing additional symptoms.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Discuss warning signs and how to avoid onset of syndrome with client/SO(s).
• Instruct client/caregivers in bowel and bladder care, prevention of skin breakdown, care of existing skin breaks, prevention of infection.
• Instruct family member/healthcare provider in blood pressure monitoring during acute episodes.
• Review proper use/administration of medication if indicated.
• Assist client/family in identifying emergency referrals (e.g., physician, rehabilitation nurse/home care supervisor). Place phone number(s) in prominent place.
• Refer to ND risk for Autonomic Dysreflexia.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, noting previous episodes, precipitating factors, and individual signs/symptoms.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.

IMPLEMENTATION/EVALUATION
• Client’s responses to interventions and actions performed, understanding of teaching.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.