Spinal Cord Injury

Problem # 1Nursing diagnosis-Risk for autonomic dysreflexia

r/t exaggerated unopposed autonomic response to noxious stimuli for individuals with SCI at or above T6

Subjective cuesPounding headache (caused by the elevation in blood pressure)

Objective cuesGoose pimplesSweating above the level of injuryNasal congestionSlow pulse ( < 60 BPM)Blotching of the skinRestlessnessHypertension ( BP > 200/100)Flushed (reddened) faceRed blotches on the skin above level of spinal injurySweating above level of spinal injuryNauseaCold, clammy skin below level of spinal injury

After 30 min of NI the patient and significant other verbalize atleast 5 factors that cause AD, 5 factors of treatment and prevention, and 3 interventions when immediate emergency treatment is indicated

After ________ of NI the patient will be free of autonomic dyreflexia as evidenced by BP within patient’s baseline range, HR 60-100 bpm, and absence of headache and other clinical indicators of AD.

Problem # 2

Ineffective airway clearance

r/t neuromuscular paralysis/weakness or restriction of chest expansion occurring with halo vest obstruction.

Problem # 3

Risk for ineffective cerebral tissue perfusion and risk for decreased cardiac tissue perfusion

r/t relative hypovolemia occurring with decreased vasomotor tone