Nurse's Pocket Guide

isk 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.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Neurological Status: Autonomic
NIC—Dysreflexia Management
risk for Autonomic Dysreflexia
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
patients with injuries at T7 and T8)
Risk Factors
An injury at T6 or above or a lesion at T6 or above AND at least
one of the following noxious stimuli:
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
108 Cultural Collaborative Community/Home Care