Assess for risk factors of dysreflexia, such as constipation, fecal impaction, distended bladder, and presence of noxious stimuli. Identifying risk factors can prevent or minimize dysreflexic episodes.- Monitor and record intake and output accurately to ensure adequate fluid replacement, thereby helping to prevent constipation.
- Check for bladder distention and patency of catheter. A blocked catheter can trigger dysreflexia.
- Check for abdominal distention and assess bowel sounds. Monitor and record characteristics and frequency of stools. Fecal impaction may lead to dysreflexia.
- Monitor vital signs frequently to ensure effectiveness of preventive measures. Severe hypertension may indicate dysreflexia.
- Encourage fluid intake of 3 L daily, unless contraindicated. Adequate fluid intake helps maintain patency of catheter and aids bowel elimination.
- Administer laxative, enema, or suppositories, as prescribed, to promote elimination of solids and gases from GI tract. Monitor effectiveness.
Consult with dietitian about increasing fiber and bulk in diet to maximum prescribed by physician to improve intestinal muscle tone and promote comfortable elimination.
Implement and maintain bowel and bladder programs to avoid stimuli that could trigger dysreflexia.
Instruct patient, family members, or caregiver about risk factors, signs and symptoms, and care measures for dysreflexia to help prevent a possible dysreflexic episode and help patient respond appropriately should dysreflexia occur. Suggest patient carry an autonomic dysreflexia emergency card such as the one from www.sci-info-pages.com to provide information quickly for responders unfamiliar with autonomic dysreflexia.
Suggested NIC Interventions
Dysreflexia Management; Neurologic Monitoring; Vital Signs Monitoring |