Assessment Subjective: Ang sakit ng ulo ko at parang barado yung ilong ko Objective: Vital Signs BP:160/100mmHg PR: 59bpm

RR: 24cpm T:36 >Paroxysmal increase in blood pressure of 160/100 >Bradycardic with pulse rate of 59 >Oliguria with urine output of 400 ml/day >Hypoactive bowel of 2 sounds in 2 minutes >Red splotches on skin and diaphoretic above the level of spinal injury >facial erythema >Presence of goose flesh and pallor

Nursing Diagnosis Autonomic Dysreflexia related to bladder/bowel distention secondary to spinal cord injury

Scientific Explanation Below the t6 injury, intact peripheral sensory nerves transmit impulses that ascend in the spinothalamic and posterior columns to stimulate sympathetic neurons located in the intermediolateral gray matter of the spinal cord.. This large sympathetic outflow causes release of various neurotransmitters (norepinephrine, dopamine-bhydroxylase, and dopamine), causing piloerection, skin pallor, and severe vasoconstriction in arterial vasculature. The result is sudden elevation in blood pressure.

Planning

Nursing Intervention

Rationale

Evaluation

After 1 hour of Independent: nursing >Placed the patient in an intervention the upright seated position with patient will: legs down and remove constrictive clothing or 1. Be Remove devices from any stimuli that are causing the hyperactivity >After confirming a bladder of the autonomic distension, perform nervous system. immediate catheterization 2. Have a stable vital signs as evidenced by a decrease in systolic blood pressure of 20-40 mmHg and an increase in pulse rate of 60-80 bpm 3. Prevent any complication caused by an unstable condition

>Provide digital stimulation of the anus and prepare the patient for manual extraction of the feces >Carefully investigate any other stimulus such as the environmental temperature that may contribute in the condition

4. Allay restlessness >Continue to monitor the patient especially the Vital Signs every 3-5 minutes

After 1 hour of >This maneuver provokes nursing an orthostatic drop in intervention, the blood pressure by patient: allowing pooling of blood in the abdomen and lower 1. Has been extremities removed from the stimuli that >This allows the were causing emptying of urine in the the bladder that is causing the hyperactivity of stimulation of stretch the autonomic receptors that participates nervous system. in the activation of sympathetic response 2. Had a stable vital signs of >This allows the Blood pressure evacuation of the feces of 130/90 and a because of constipation pulse rate of 70 that is triggering the beats per minute exacerbation. 3. Has been >This provides a prevented from maximum possible having a serious improvement of the complications patients condition associated with unstable vital signs >To assess the effectiveness of every 4.Has been interventions being allayed from carried out restlessness

below the level of spinal injury >partial ptosis of the eyelid >restlessness >X-ray result shown fracture of the spine at the level of t6 >MRI result shown spinal cord damage at the level of t6

Vasomotor brainstem reflexes attempt to lower blood pressure by increasing parasympathetic stimulation to the heart through the vagus nerve to cause compensatory bradycardia. The inhibitory outflow above the SCI from cerebral vasomotor centers is increased, but it is unable to pass below the block of the SCI Patients commonly have a headache caused by vasodilation of pain sensitive intracranial vessels. This reflex action cannot compensate for severe

Dependent: >Adminiter medications as prescribed: >It relaxes the patient and Morphine Sulfate reduces the pain that is contributing to the spike of sympathetic response >A Calcium channel Nifedipine blocker that reduces the blood pressure >It is being administered Phentotalamine via IV if the calcium channel blocker is ineffective >This allows the blockage Lignocaine Gel of afferent input when performing painful procedures such as manual extraction of feces and catheterization

vasoconstriction, explained by the Poiseuille formula, where pressure in a tube is affected to the fourth power by change in radius (vasoconstriction) and only linearly by change in flow rate (bradycardia). Parasympathetic nerves prevail above the level of injury, which may be characterized by profuse sweating and vasodilation with skin flushing.