Nursing Dx

Taxonomy II: Coping/Stress Tolerance—Class 3
Neurobehavioral Stress (00010)
[Diagnostic Division: Circulation]
Nursing Diagnosis Extension and Classification (NDEC)
Submission 1998/Revised 2000

Definition: At risk for life-threatening, uninhibited response of the sympathetic nervous system post spinal shock, in an individual with a spinal cord injury [SCI] or lesion at T6 or above (has been demonstrated in clients with injuries at T7 and T8)

Risk Factors
MUSCULOSKELETAL—INTEGUMENTARY STIMULI
Cutaneous stimulations (e.g., pressure ulcer, ingrown toenail, dressing, burns, rash); sunburns; wounds Pressure over bony prominences or genitalia; range-of-motion exercises; spasms
Fractures; heterotrophic bone
GASTROINTESTINAL STIMULI
Constipation; difficult passage of feces; fecal impaction; bowel distention; hemorrhoids
Digital stimulation; suppositories; enemas
Gastrointestinal system pathology; esophageal reflux; gastric ulcers; gallstones
UROLOGICAL STIMULI
Bladder distention/spasm
Detrusor sphincter dyssynergia

Instrumentation or surgery; calculi
Urinary tract infection; cystitis; urethritis; epididymitis
REGULATORY STIMULI
Temperature fluctuations; extreme environmental temperatures
SITUATIONAL STIMULI
Positioning; surgical procedure
Constrictive clothing (e.g., straps, stockings, shoes)
Drug reactions (e.g., decongestants, sympathomimetics, vasoconstrictors, narcotic withdrawal)
NEUROLOGICAL STIMULI
Painful or irritating stimuli below the level of injury
CARDIAC/PULMONARY STIMULI
Pulmonary emboli; deep vein thrombosis
REPRODUCTIVE [AND SEXUALITY] STIMULI
Sexual intercourse; ejaculation
Menstruation; pregnancy; labor and delivery; ovarian cyst
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify risk factors present.
• Demonstrate preventive/corrective techniques.
• Be free of episodes of dysreflexia.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess risk factors present:
• Monitor for potential precipitating factors, including urological (e.g., bladder distention, urinary tract infections, kidney stones); gastrointestinal (bowel overdistention, hemorrhoids, digital stimulation); cutaneous (e.g., pressure ulcers, extreme external temperatures, dressing changes); reproductive (e.g., sexual activity, menstruation, pregnancy/delivery); and miscellaneous (e.g., pulmonary emboli, drug reaction, deep vein thrombosis).

NURSING PRIORITY NO. 2. To prevent occurrence:
• Monitor vital signs, noting changes in blood pressure, heart rate, and temperature, especially during times of physical stress to identify trends and intervene in a timely manner.

• Instruct in preventive interventions (e.g., routine bowel care, appropriate padding for skin and tissue care, proper positioning, temperature control).
• Instruct all care providers in safe and necessary bowel and bladder care, and immediate and long-term care for the prevention of skin stress/breakdown. These problems are associated most frequently with dysreflexia.
• Administer antihypertensive medications when at-risk client is placed on routine “maintenance dose,” as might occur when noxious stimuli cannot be removed (presence of chronic sacral pressure sore, fracture, or acute postoperative pain).
• Refer to ND Autonomic Dysreflexia.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Discuss warning signs of autonomic dysreflexia with client/ caregiver (i.e., congestion, anxiety, visual changes, metallic taste in mouth, increased blood pressure/acute hypertension, severe pounding headache, diaphoresis and flushing above the level of SCI, bradycardia, cardiac irregularities). Early signs can develop rapidly (in minutes), requiring quick intervention.
• Review proper use/administration of medication if preventive medications are anticipated.
• Assist client/family in identifying emergency referrals (e.g., healthcare provider number in prominent place).

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.