Case

Autonomic dysreflexia 60-year-old male paraplegic, arrives at triage in a local emergency department with reports of a severe headache. Case study

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Course
NR 351

Institution
Chamberlain College Of Nursing

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Uploaded on September 2, 2024
Number of pages 3
Written in 2023/2024
Type Case
Professor(s) Nur290
Grade A+

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Group 2: Case Study
Patient care primary diagnosis Autonomic dysreflexia
60-year-old male paraplegic, arrives at triage in a local emergency department with reports of a
severe headache. The patient may be experiencing AD known as Autonomic dysreflexia which if
not corrected can be life threatening. This is a serious medical condition that happens if there is a
spinal cord injury. AD causes your blood pressure to increase to dangerously high levels coupled
with low heart beat which can lead to stroke, seizure or cardiac arrest and we must move fast to
determine the cause.
Provide the appropriate steps and processes the RN would use to care for the patient
experiencing the medical emergency, include rationales for each step as you prioritize.
A head-to-toe assessment needs to be done including assessing the skin for red blotchy areas. Look for
sweating above level of injury. Assess vital signs as AD can cause slow a heart rate since high blood
pressure slows the heart ate to reduce the work load of the heart. Assess integumentary system for
goose bumps, cold sweats, and assess for anxiety. Identify the cause of AD quickly by checking for tight
clothing. Take all restrictive clothing off, and if there are tight shoes. Sit the patient upright, assess the
foley catheter if the f/c is kinked or obstructed. Is the bladder full and needs to be straight catheterized?
UTIs cause AD. Check bm abdominal assessment for bowel impaction since this can cause AD.
Assessment of skin integrity needs to be done for pressure injury such as ingrown toe nail.
Describe which of the steps can be delegated to a UAP and why they can be delegated.
The UAP can connect the blood pressure monitor and set it for every 5 to 10 minutes depending on the
order from the physician, and help to monitor the readings for increases and decreases, and pulse
oximeter, and if the patient has a urinary catheter, then the UAP can check the line for kinks and the
volume in the bag, because that is within the scope of practice for the UAP. The UAP can also collect
some supplies for the care team depending on what we might need. The UAP can also help with
transporting the patient to a different location.
Identify and describe the importance of three specific resources the RN needs to care
for the patient.
Vital sign equipment to monitor blood pressure and heart rate, bladder scanner to determine
bladder volume, scissors to cut tight clothing, Stat abdominal Xray to determine fecal
impaction. Access to laboratory equipment, a Catheter kit to be able to catheterize the patient
to relieve the bladder if needed. Access to medications such as a nitro paste for the skin,
clonidine or IV hydralazine to help bring the blood pressure down if the bladder and bowel
interventions do not work.
Provide three recommendations for communicating with colleagues and families about
the patient’s medical emergency, include the mode of communication and the rationale
why you chose this communication style.
As the nurse, the mode of communication I would choose would be Interpersonal
communication. I would listen communicate and educate the patient regarding the
severity of this condition. As I would be communicating with him, I would watch his body
language and facial expressions to determine if he is understanding the information
provided to him. I would listen in return to his concerns and answer any questions he
may have.

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