- Autonomic Dysreflexia related to Painful stimuli below the level of injury as evidenced by diaphoresis above the level of injury and pallor below the level of injury
- Impaired Physical Mobility related to Neuromuscular dysfunction and Joint stiffness as evidenced by Inability to move purposely and Decreased range of motion
- Impaired Sitting/Standing/Transfer Ability related to Insufficient muscle strength and loss of sensation in the lower extremities as evidenced by difficulty adjusting the position of one or both lower limbs on an uneven surface and difficulty flexing/extending one or both knees
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Expression discomfort with movement Objective data: -Severe headache -Bradycardia -Tachycardia -Chest pain -Nasal congestion -Paresthesia -Diaphoresis above the level of injury -Pallor below the level of injury | Autonomic Dysreflexia related to Painful stimuli below the level of injury as evidenced by diaphoresis above the level of injury and pallor below the level of injury | Patient will maintain vital signs within normal limits. Patient and caregivers will verbalize the causes and prevention of autonomic dysreflexia. | 1. Place the patient in an upright position. The first immediate step is to assist the patient into a high-Fowler’s or upright position with the legs dangling in an effort to reduce the blood pressure. 2. Remove constricting clothing or devices. Loosen or remove tight clothing, shoes, compression stockings, and binders, and ensure IV lines and catheters are not pressing into the skin. 3. Check bladder and bowel function. Kinked catheters and bladder distention are common causes of autonomic dysreflexia. Obtain a urinalysis as another potential source. If normal, an evaluation for fecal impaction should occur next. 4. Assess for skin abnormalities. If bladder and bowel assessments are normal, the nurse should next evaluate the skin for wounds, pressure ulcers, ingrown toenails, etc. 5. Administer antihypertensive medications as indicated. Nitroglycerin 2% paste is the initial medication administered for hypertension in autonomic dysreflexia. Immediate-release nifedipine is the next preferred medication choice. 6. Continue to monitor blood pressure. The nurse should reassess the blood pressure every three to five minutes during an episode and for up to two hours after the episode. 7. Accurately document the incident, including precipitating factors. It is important to document any episodes of autonomic dysreflexia, including the precipitating cause. This is especially important if the trigger is unusual. 8. Educate the patient and caregivers about autonomic dysreflexia. Autonomic dysreflexia occurs in about 90% of paraplegic patients with spinal cord injuries at or above the level of T6. The nurse should educate the patient and family/caregivers about the causes and symptoms of this disorder to prevent life-threatening complications. | Patient maintained vital signs within normal limits. Patient and caregivers verbalized the causes and prevention of autonomic dysreflexia. |
| Subjective data: -Expression of pain and discomfort with movement Objective data: -Limited range of motion -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Decreased muscle strength | Impaired Physical Mobility related to Neuromuscular dysfunction and Joint stiffness as evidenced by Inability to move purposely and Decreased range of motion | Patient will demonstrate the use of assistive devices effectively. Patient will participate in rehabilitation and physical therapy as prescribed. | 1. Accommodate limitations. Home settings may require ramps or lifts installed while cars can be outfitted to support wheelchairs. 2. Encourage alternative treatment. Acupuncture, massage, and chiropractic care can make mobility less painful. 3. Prepare for surgery. Some physical limitations may be relieved through surgery at the site of injury, such as removing a tumor. 4. Refer the patient to a physical therapist. Ongoing physical therapy provides appropriate rehabilitative exercises for patients with paraplegia. 5. Encourage exercise. Swimming, yoga, and seated aerobics can help with stretching to prevent muscle atrophy and promote controlled breathing to avoid respiratory complications. | Patient demonstrated the use of assistive devices effectively. Patient participated in rehabilitation and physical therapy as prescribed. |
| Subjective data: -Expression of pain and discomfort with movement -Refusal to move Objective data: -Uncoordinated movements -Poor balance Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Decreased muscle strength | Impaired Sitting/Standing/Transfer Ability related to Insufficient muscle strength and loss of sensation in the lower extremities as evidenced by difficulty adjusting the position of one or both lower limbs on an uneven surface and difficulty flexing/extending one or both knees | Patient will demonstrate independence with sitting/standing/transferring within their physical capabilities. Patient will demonstrate the use of assistive devices to sit/stand/transfer | 1. Assist the patient in performing range of motion exercises. Range of motion exercises can help improve circulation, prevent contractures and atrophy, and restore muscle tone. 2. Refer the patient to occupational and physical therapy. Physical and occupational therapists can help patients develop appropriate exercise and strengthening programs and advise on equipment and devices to aid mobility. 3. Instruct on the use of mobility aids and transfer devices. Mobility and transfer devices such as slide boards, lifts, walkers, wheelchairs, canes, and more can help paraplegic patients move, sit, stand, and transfer from one position to another while reducing the risk of injury and falls. 4. Consider the use of braces and orthotics. The nurse can discuss fitting the client with braces or orthotics to aid in stabilizing the knee, ankle, or foot to assist with movement. | Patient demonstrated independence with sitting/standing/transferring within their physical capabilities. Patient demonstrated the use of assistive devices to sit/stand/transfer |