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NUR2502 MULTIDIMENSIONAL CARE III FINAL EXAM OUTLINE

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NUR2502 MULTIDIMENSIONAL CARE III FINAL EXAM OUTLINE •Autonomic Dysreflexia: S/S: Sudden rise in BP with Bradycardia. Profuse sweating above Injury. flushing of skin. Blurred/Spots in vision. ... Nasal congestion Causes: Urine Retention! Sympathetic Nervous System is Stimulated = Patient Goes into Overdrive Straight Cath Bladder Distention/UTI Constipation Pain, Temp Fluxuations GI, GU Vascular Stimulation Interventions: AD is neurologic emergency & must Be Promptly treated to prevent Hypertensive Stroke! If pt experiences AD, raise head of bed immediately to help reduce BP. Place pt in a sitting position (First Priority!), or return to previous safe position. Check for urinary retention or Catheter Blockage: Check urinary catheter tubing (if Present) for Kinks or Obstruction. 1.If Urinary Catheter is not present, check for Bladder Distention & Catheterize immediately if indicated: 2.Consider using anesthetic ointment on tip of catheter before catheter insertion to ↓ urethral irritation. Determine if Urinary tract infection or Bladder Calculi (Stones) are contributing to genitourinary irritation. Check pt for Fecal Impaction or other colorectal irritation, Using Anesthetic Ointment at rectum. Disimpact if needed. Examine skin for new or worsening pressure injury s/s. Monitor BP q 10-15 Min. Give Nifedipine or Nitrate to Lower BP. Paralytic Ileus may develop within 72 hrs of Hospital Admission. [Show More]

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