Nurse's Pocket Guide

urine flow if blocked; remove bowel impaction or stop digital
stimulation; reduce skin pressure by changing position or
removing restrictive clothing; protect from temperature
extremes).
• Elevate head of bed as high as tolorated or place client in sitting
position with legs dangling 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.)
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Discuss warning signs and how to avoid onset of syndrome
with client/SO(s). Knowledge can support adherence to
preventative measures and promote prompt intervention
when required. Note: If cause cannot be detected, or
situation quickly resolved, contact physician immediately
for further interventions to reduce risk of serious complications.
• Instruct client/caregivers in preventative care (e.g., safe and
timely bowel and bladder care; prevention of skin breakdown;
care of existing skin breaks; prevention of infection).
• Instruct family member/caregiver in blood pressure monitoring
and discuss plan for monitoring and treatment of high
blood pressure during acute episodes.
• Review proper use/administration of medication if indicated.
Client may have medication(s) both for emergent situations
and/or prevention of AD.
• Assist client/family in identifying emergency referrals (e.g.,
physician, rehabilitation nurse/home care supervisor). Place
phone number(s) in prominent place.
• Recommend wearing Medical Alert bracelet/necklace and
carrying information card reviewing client’s typical signs/
symptoms and usual methods of treatment. Provides vital
information to care providers in emergent situation.
• Refer for advice/treatment of sexual and reproductive concerns
as indicated.
• Refer to ND risk for Autonomic Dysreflexia.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 107
AUTONOMIC DYSREFLEXIA