Neurogenic Shock Nursing Care Management

Mila and her friends went partying on a Friday night. Her friend, who was drunk, drove them home. As they were crossing an intersection, their car was hit by a ten-wheeler truck. Mila sustained a spinal cord injury. Upon arrival at the emergency department, her BP was 80/40, she had warm, dry skin, and her pulse is 44 beats per minute. Mila is progressing towards neurogenic shock due to spinal cord injury.

Description


Neurogenic shock is a distributive type of shock.

  • In neurogenic shock, vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation.
  • It is a type of shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body) that is caused by the sudden loss of signals from the sympathetic nervous system that maintain the normal muscle tone in blood vessel walls.

Pathophysiology


The patient experiences the following that results in neurogenic shock:

  • Stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate.
  • Vasodilation. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period of time, leading to a relative hypovolemic state.
  • Hypotension. Blood volume is adequate, because the vasculature is dilated; the blood volume is displaced, producing a hypotensive (low BP) state.
  • Cardiovascular changes. The overriding parasympathetic stimulation that occurs with neurogenic shock causes a drastic decrease in the patient’s systemic vascular resistance and bradycardia.
  • Insufficient perfusion. Inadequate BP results in the insufficient perfusion of tissues and cells that is common to all shock states.

Statistics and Incidences


Statistics regarding neurogenic shock are:

Causes


Neurogenic shock could be caused by the following:

  • Spinal cord injury. Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock).
  • Spinal anesthesia. Spinal anesthesia—injection of an anesthetic into the space surrounding the spinal cord—or severance of the spinal cord results in a fall in blood pressure because of dilation of the blood vessels in the lower portion of the body and a resultant diminution of venous return to the heart.
  • Depressant action of medications. Depressant action of medications and lack of glucose could also cause neurogenic shock.

Clinical Manifestations


The clinical manifestations of neurogenic shock are signs of parasympathetic stimulation.

  • Dry, warm skin. Instead of cool, moist skin, the patient experiences dry, warm skin due to vasodilation and inability to vasoconstrict.
  • Hypotension. Hypotension occurs due to sudden, massive dilation.
  • Bradycardia. Instead of getting tachycardic, the patient experience bradycardia.
  • Diaphragmatic breathing. If the injury is below the 5th cervical vertebra, the patient will exhibit diaphragmatic breathing due to loss of nervous control of the intercostal muscles (which are required for thoracic breathing).
  • Respiratory arrest. If the injury is above the 3rd cervical vertebra, the patient will go into respiratory arrest immediately following the injury, due to loss of nervous control of the diaphragm.

Assessment and Diagnostic Findings


Diagnosis of neurogenic shock is possible through the following tests:

  • Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray.
  • Xrays. Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after trauma.
  • Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to produce computer-generated images.

Medical Management


Treatment of neurogenic shock involves:

  • Restoring sympathetic tone. It would be either through the stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient appropriately.
  • Immobilization. If the patient has a suspected case of spinal cord injury, a traction may be needed to stabilize the spine to bring it to proper alignment.
  • IV fluids. Administration of IV fluids is done to stabilize the patient’s blood pressure.

Pharmacologic Therapy

Drugs administered to a patient undergoing neurogenic shock are:

  • Inotropic agents. Inotropic agents such as dopamine may be infused for fluid resuscitation.
  • Atropine. Atropine is given intravenously to manage severe bradycardia.
  • Steroids. Patient with obvious neurological deficit can be given I.V. steroids, such as methylprednisolone in high dose, within 8 hours of commencement of neurogenic shock.
  • Heparin. Administration of heparin or low molecular-weight heparin as prescribed may prevent thrombus formation.

Nursing Management


Nursing management of a patient with neurogenic shock includes:

Nursing Assessment

Assessment of a patient with neurogenic shock should involve:

  • ABC assessment. The prehospital provider should follow the basic airway, breathing, circulation approach to the trauma patient while protecting the spine from any extra movement.
  • Neurologic assessment. Neurologic deficits and a general level at which abnormalities began should be identified.

Nursing Diagnosis

Based on the assessment data, the nursing diagnoses for a patient with neurogenic shock are:

  • Risk for impaired breathing pattern related to impairment of innervation of diaphragm (lesions at or above C-5).
  • Risk for trauma related to temporary weakness/instability of spinal column.
  • Impaired physical mobility related to neuromuscular impairment.
  • Disturbed sensory perception related to destruction of sensory tracts with altered sensory reception, transmission, and integration.
  • Acute pain related to pooling of the blood secondary to thrombus formation.

Nursing Care Planning & Goals

The major goals for the patient include:

  • Maintain adequate ventilation as evidenced by absence of respiratory distress and ABGs within acceptable limits
  • Demonstrate appropriate behaviors to support the respiratory effort.
  • Maintain proper alignment of spine without further spinal cord damage.
  • Maintain position of function as evidenced by absence of contractures, foot drop.
  • Increase strength of unaffected/compensatory body parts.
  • Demonstrate techniques/behaviors that enable resumption of activity.
  • Recognize sensory impairments.
  • Identify behaviors to compensate for deficits.
  • Verbalize awareness of sensory needs and potential for deprivation/overload.

Nursing Interventions

Nursing interventions are directed towards supporting cardiovascular and neurologic function until the usually transient episode of neurogenic shock resolves.

  • Elevate head of bed. Elevation of the head helps prevent the spread of the anesthetic agent up the spinal cord when a patient receives spinal or epidural anesthesia.
  • Lower extremity interventions. Applying anti-embolism stockings and elevating the foot of the bed may help minimize pooling of the blood in the legs and prevent thrombus formation.
  • Exercise. Passive range of motion of the immobile extremities helps promote circulation.
  • Airway patency. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated.
  • Oxygen. Administer oxygen by appropriate method (nasal prongs, mask, intubation, ventilator).
  • Activities. Plan activities to provide uninterrupted rest periods and encourage involvement within individual tolerance and ability.
  • BP monitoring. Measure and monitor BP before and after activity in acute phases or until stable.
  • Reduce anxiety. Assist patient to recognize and compensate for alterations in sensation.

Evaluation

Expected patient outcomes are:

  • Maintained adequate ventilation.
  • Demonstrated appropriate behaviors to support the respiratory effort.
  • Maintained proper alignment of spine without further spinal cord damage.
  • Maintained position of function.
  • Increased strength of unaffected/compensatory body parts.
  • Demonstrated techniques/behaviors that enable resumption of activity.
  • Recognized sensory impairments.
  • Identified behaviors to compensate for deficits.
  • Verbalized awareness of sensory needs and potential for deprivation/overload.

Documentation Guidelines

The focus of documentation are:

  • Relevant history of problem.
  • Respiratory pattern, breath sounds, use of accessory muscles.
  • Laboratory values.
  • Past and recent history of injuries, awareness of safety needs.
  • Use of safety equipment or procedures.
  • Environmental concerns, safety issues.
  • Level of function, ability to participate in specific or desired activities.
  • Client’s description of response to pain, specifics of pain inventory, expectations of pain management, and acceptable level of pain.
  • Prior medication use.
  • Plan of care, specific interventions, and who is involved in the planning.
  • Teaching plan.
  • Response to interventions, teaching, actions performed, and treatment regimen.
  • Attainment or progress towards desired outcomes.
  • Modifications to the plan of care.

Practice Quiz: Neurogenic Shock


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1. When administering dopamine (Intropin), it is most important for the nurse to know that:

A. The drug’s action varies according to the dose.
B. The drug may be used instead of fluid replacement.
C. The drug cannot be directly mixed in solutions containing bicarbonate or aminophylline.
D. The lowest dose to produce the desired effect should be used.

1. Answer: C. the drug cannot be directly mixed in solutions containing bicarbonate or aminophylline.

  • C: The nurse is responsible for knowing compatible solutions before administering dopamine (Intropin).
  • A: It is important to know that drug action varies by dose, but the physician is responsible for determining the dose.
  • B: Dopamine should not be used instead of fluid replacement.
  • D: Choice D is incorrect because, although it is true, it is not the nurse’s primary concern.

2. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?

A. Autonomic dysreflexia.
B. Hypervolemia.
C. Neurogenic shock.
D. Sepsis.

2. Answer: C. Neurogenic shock

  • C: Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock.
  • A: Autonomic dysreflexia occurs after neurogenic shock abates.
  • B: Hypervolemia is indicated by rapid and bounding pulse and edema.
  • D: Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.

3. The nurse is planning care for the client in neurogenic shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?

A. Monitoring vital signs before and during position changes
B. Using vasopressor medications as prescribed
C. Moving the client quickly as one unit
D. Applying Teds or compression stockings.

3. Answer: C. Moving the client quickly as one unit.

  • C: Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound.
  • A: Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client’s position slowly.
  • B: Vasopressor medications are administered per protocol.
  • D: Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots.

4. The nurse is evaluating neurological signs of the male client in neurogenic shock following spinal cord injury. Which of the following observations by the nurse indicates that neurogenic shock persists?

A. Positive reflexes.
B. Hyperreflexia.
C. Inability to elicit a Babinski’s reflex.
D. Reflex emptying of the bladder.

4. Answer: C. Inability to elicit a Babinski’s reflex.

  • C: Resolution of neurogenic shock is occurring when there is a positive Babinski’s reflex.
  • A, B, D: There is a resolution of neurogenic shock if there is a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a return of reflexes.

5. A patient with a spinal cord injury is recovering from neurogenic shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

A. Autonomic dysreflexia.
B. Autonomic crisis.
C. Autonomic shutdown.
D. Autonomic failure.

5. Answer: A. Autonomic dysreflexia.

  • A: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia.
  • B, C, D: Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

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Further Reading and Recommended Resources


Recommended books and reading materials:
  1. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
  2. Medical-Surgical Nursing: Assessment and Management of Clinical Problems
  3. Medical-Surgical Nursing: Patient-Centered Collaborative Care
  4. Saunders Comprehensive Review for the NCLEX-RN Examination
  5. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
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