A client who sustained a C4 spinal cord injury in a motor vehicle collision earlier today is admitted to the trauma intensive care unit. The nurse suspects the development of a distributive shock state related to the loss of sympathetic vascular tone. Which assessment findings validate this clinical deterioration? Select all that apply.
- Apical pulse of 42 beats/minAnswer
- Blood pressure of 82/40 mm HgAnswer
- CCool, clammy skin on the lower extremities
- Core body temperature of 35.2°C (95.4°F)Answer
- ESudden, pounding headache and diaphoresis
- FTachycardia with a heart rate of 118 beats/min
Answer
The clinical findings that validate the development of neurogenic shock are an apical pulse of 42 beats/min, a blood pressure of 82/40 mm Hg, and a core body temperature of 35.2°C (95.4°F).
Neurogenic shock occurs as a result of a disruption in the descending sympathetic pathways in the spinal cord, most commonly from injuries above the T6 level. The loss of sympathetic tone causes massive peripheral vasodilation (resulting in severe hypotension), leaves the parasympathetic nervous system unchecked (resulting in profound bradycardia), and impairs the body's ability to regulate core temperature (resulting in heat loss and hypothermia). Identifying this specific triad of symptoms is critical for adapting fluid and vasopressor therapies appropriately.
Step-by-Step Solution
Key Concept
Neurogenic shock is a hemodynamic syndrome characterized by hypotension, bradycardia, and hypothermia, resulting from the loss of sympathetic nervous system tone following a high spinal cord injury.