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Difficulty: Very hardPhysiological Adaptation

A practical nurse (PN) is collecting data on a client who was admitted 12 hours ago with a complete spinal cord injury at the T2 level. The client's baseline blood pressure was 128/78 mm Hg and heart rate was 86 bpm. The client now reports feeling dizzy and lightheaded. Current vital signs are: blood pressure 94/56 mm Hg, heart rate 62 bpm, and respiratory rate 18 breaths/min. The PN notes the client's skin is flushed, warm, and dry to the touch. Which of the following actions should the PN take immediately? Select all that apply.

  1. Immediately notify the registered nurse (RN) of the vital sign changes.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position.
  3. Prepare to assist the RN with the administration of intravenous isotonic fluids.Answer
  4. D
    Document the warm skin and vital signs as expected, stable findings.
  5. Apply a pulse oximeter and provide supplemental oxygen as prescribed.Answer
  6. F
    Prepare to administer a PRN dose of oral acetaminophen.

Answer

The correct actions are to immediately notify the RN, prepare to assist with intravenous isotonic fluids, and apply a pulse oximeter while providing supplemental oxygen.
The client is exhibiting subtle but classic signs of early neurogenic shock (hypotension, relative bradycardia, and warm/flushed skin due to vasodilation) secondary to a T2 spinal cord injury. The correct priority actions are to escalate the emergency by notifying the RN, support circulation by assisting with intravenous isotonic fluids, and ensure adequate oxygenation by applying supplemental oxygen.

Step-by-Step Solution

1
Compare the current vital signs and physical assessment to the client's baseline.
The blood pressure has dropped significantly (by 34 mm Hg systolic), the heart rate is inappropriately low for the level of hypotension (bradycardia at 62 bpm), and the skin is flushed and warm.
Recognizing subtle deviations from baseline is critical for the early identification of life-threatening complications.
2
Correlate the clinical findings with the client's high thoracic (T2) spinal cord injury.
The cluster of symptoms indicates a loss of sympathetic nervous system tone below the level of the injury, leading to massive vasodilation.
This pathophysiology confirms the development of neurogenic shock rather than hypovolemic shock, which would typically present with compensatory tachycardia and cold, clammy skin.
3
Prioritize nursing interventions based on the practical nurse (PN) scope of practice.
The appropriate actions are notifying the RN to escalate care, preparing to assist with IV fluid resuscitation to correct relative hypovolemia, and applying oxygen to support tissue perfusion.
These actions directly address the immediate ABC priorities (Airway, Breathing, Circulation) without causing harm or exceeding the PN's scope.

Key Concept

Early recognition of neurogenic shock in high spinal cord injuries
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Topics

Physiological Adaptation

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