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Difficulty: MediumPhysiological Adaptation

A client is admitted to the neurotrauma unit following a complete spinal cord injury at the C5 level. Several hours after admission, the nurse assesses the client and finds a blood pressure of 82/46 mm Hg, a heart rate of 44 beats/minute, and warm, flushed skin on the extremities. Based on these clinical findings, which intervention should the nurse anticipate as the highest priority?

  1. A
    Initiate a rapid infusion of intravenous crystalloids and prepare for a blood transfusion.
  2. Prepare to administer intravenous atropine and a continuous vasopressor infusion.Answer
  3. C
    Elevate the head of the bed to a high-Fowler's position immediately.
  4. D
    Assess the client's indwelling urinary catheter for tubing kinks or obstructions.

Answer

The priority action is to prepare to administer intravenous atropine and a continuous vasopressor infusion.
The client's presentation of hypotension, bradycardia, and warm, flushed skin following a high spinal cord injury indicates neurogenic shock. This life-threatening condition occurs due to a sudden disruption of sympathetic nervous system pathways, leading to massive vasodilation (causing warm skin and hypotension) and unopposed parasympathetic tone (causing bradycardia). The priority intervention is to restore vascular tone using continuous vasopressor infusions and to manage the severe bradycardia with medications such as intravenous atropine.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client is exhibiting profound hypotension (82/46 mm Hg), severe bradycardia (44 beats/min), and warm, flushed skin.
Identifying abnormal vital sign patterns is the first step in recognizing life-threatening complications following a spinal cord injury.
2
Correlate the clinical findings with the mechanism of injury to identify the specific physiological complication.
The combination of a cervical spine injury, hypotension, bradycardia, and warm skin points directly to neurogenic shock, rather than hypovolemic shock.
Neurogenic shock occurs due to a massive loss of sympathetic nervous system tone, which uniquely causes bradycardia and vasodilation (warm skin) instead of the compensatory tachycardia and vasoconstriction seen in other forms of shock.
3
Determine the most appropriate immediate medical intervention to stabilize the client.
The nurse must anticipate administering vasopressors (to cause vasoconstriction and increase blood pressure) and atropine (to block vagal stimulation and increase heart rate).
Because the root cause is a loss of vasomotor tone and unopposed parasympathetic stimulation, treatment must artificially restore vascular resistance and heart rate.

Key Concept

Neurogenic Shock Recognition and Management
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Topics

Physiological Adaptation

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