Autonomic Dysreflexia

Definisi
Life-threatening, unhibited sympathetic response of the nervous system to the noxious
stimulus after a spinal cord injury at T7 or above
Karakteristik

Cardiopulmonary status
Hydration
Hypertension severity
Hypotension severity
Neorological status
Neorological status: Cranial sensory / motor function
Neorological status: peripheral
Pain level
Respiratory status
Risk control: hypothermia
Sensory function: tactile
Sensory function: vision
Vital signs
Blurred vision
Bradycardia
Chest pain
Chilling
Conjugtival congestion
Diaphoresis (above the injury)
Headache (a diffuse pain in different portions of the head ang not confined to any

nerve distribution area)

Horners syndrome
Metallic taste in mouth
Nasal congestion
Pallor (below the injury)
Paresthesia
Paroxysmal hypertension
Pilomotor reflex
Red splotches on skin (above the injury)
Tachycardia

Relatif faktor

Bladder distension
Bowel distension. Bowel elimination
Deficient caregiver knowledge. Caregiver performance: diret care
Circulation status
Knowledge: disease process

Knowledge: hypertension management

Knowledge: treatment regimen
Self-management: chronic disease
Sensory function
Symptom severity
Tissue integrity: skin and mucous membranes
Urinary elimination
Deficient patient knowledge
Skin irritation

Domain 9 (Coping / Stress Tolerance)

Class 3 (Neurobehavioral Stress)
Kode 00009

otonom dysreflexia
Definisi
mengancam jiwa, Respon simpatik tanpa hambatan dari sistem saraf terhadap stimulus
berbahaya setelah cedera tulang belakang pada T7 atau di atas
Karakteristik
Status Cardiopulmonary
Hidrasi
keparahan Hipertensi
keparahan Hipotensi
Status neurologis
Status neurologis: kranial sensorik / fungsi motorik
Status neurologis: perifer
Tingkat Nyeri
Status pernapasan
Kontrol Risiko: hipotermia
Fungsi sensorik: taktil
Fungsi sensoris: penglihatan
Tanda-tanda vital
Penglihatan kabur
Bradikardia
Nyeri dada
mengerikan, menakutkan
kemacetan konjungtiva
Diaforesis (atas cedera)
Sakit kepala (nyeri menyebar di bagian yang berbeda dari kepala ang tidak terbatas pada
area distribusi saraf)
Sindrom Horner
rasa logam di mulut
Hidung tersumbat
Pucat (bawah cedera)
Parestesia
yang datang tiba-tiba hipertensi
refleks pilomotor

 bercak-bercak merah pada kulit (di atas cedera)

Takikardia
Relatif faktor
kandung kemih distensi
usus distensi. usus eliminasi
pengetahuan pengasuh Kekurangan. Kinerja Pengasuh: perawatan langsung
Status Sirkulasi
Pengetahuan: proses penyakit
Pengetahuan: manajemen hipertensi
Pengetahuan: rejimen pengobatan
Self-manajemen: penyakit kronis
Fungsi sensoris
keparahan gejala
integritas jaringan: kulit dan membran mukosa
eliminasi urin
Pengetahuan pasien Kekurangan
Iritasi kulit
Domain 9 (Coping / Stres Toleransi)
Kelas 3 (Neurobehavioral Stres)
Kode 00009