A nurse is caring for a client with a complete T6 spinal cord injury who was admitted 2 hours ago following a motor vehicle accident. Which nursing action should be the highest priority?
The client presents with bradycardia (heart rate 52 bpm), hypotension (blood pressure 88/50 mmHg), and reports feeling dizzy and nauseous.
1Administer prescribed atropine 0.5 mg IV push immediately
2Insert a nasogastric tube to prevent aspiration
3Apply sequential compression devices to prevent deep vein thrombosis
4Assess for neurogenic shock and initiate continuous cardiac monitoring✓ 정답
해설
Neurogenic shock is a life-threatening complication in acute T6 spinal cord injury, requiring immediate assessment and monitoring. Other options are important but secondary to stabilizing cardiovascular status.
Clinical Judgment
This question assesses the ability to recognize a life-threatening emergency called Autonomic Dysreflexia (AD) and select immediate nursing interventions based on priority. Two weeks after a spinal cord injury at T6 or above, the patient shows classic AD symptoms: hypertension (200/110 mmHg), bradycardia (48 bpm), headache, flushing above the injury level, and pallor below. The key judgment lies in removing the cause. AD is an exaggerated sympathetic nervous system response to a noxious stimulus below the injury level (most commonly bladder distension). Therefore, the priority is to change the patient's position to lower blood pressure while quickly identifying and removing the most common trigger.
Memory TipHead up, Bladder out!
Remember the priority interventions for AD: High Fowler's position and checking for Bladder distension.
KR vs US
In Korea, immediately reporting to the physician is heavily emphasized, but in NGN/US nursing, the first action the nurse must independently perform right away is considered more important. Reporting is essential, but before waiting for a report, you must start by changing the patient's position and checking for the cause (such as bladder distension).
Clinical Scenario
A client with a complete T6 spinal cord injury presents 2 hours post-accident with bradycardia (HR 52), hypotension (88/50), dizziness, and nausea. The priority is to assess for neurogenic shock and initiate continuous cardiac monitoring.
Nursing Actions
Assessment First: Place the client on a cardiac monitor and pulse oximeter. Obtain a full set of vital signs, including orthostatic measurements if safe, and perform a focused neurological assessment to document the level of injury and any changes.
Recognize Neurogenic Shock: Look for the triad of hypotension, bradycardia, and warm, dry skin below the injury level due to loss of sympathetic tone. Differentiate from hypovolemic shock (which presents with tachycardia and cool, clammy skin).
Continuous Monitoring: Monitor heart rate and rhythm continuously for worsening bradycardia or arrhythmias. Track blood pressure every 5-15 minutes initially. Assess for symptoms of cerebral hypoperfusion such as worsening dizziness, confusion, or decreased level of consciousness.
Prepare for Interventions: After assessment and confirmation of neurogenic shock, anticipate orders for IV fluids (cautiously to avoid fluid overload) and vasopressors or atropine if bradycardia becomes symptomatic and severe. Ensure IV access is patent.
Prevent Secondary Injury: Maintain spinal immobilization and log-roll the client for any position changes. Keep the head of the bed flat or slightly elevated as ordered to promote cerebral perfusion while protecting the spine.
Key Reminders
Assessment always precedes intervention in the nursing process, especially in unstable clients.
Neurogenic shock is a life-threatening emergency requiring immediate recognition and monitoring.
Bradycardia in spinal cord injury is due to unopposed vagal tone; treat only after confirming the rhythm.
Neurogenic shock — A type of distributive shock from loss of sympathetic tone after spinal cord injury above T6, causing hypotension and bradycardia.
Spinal shock — Temporary loss of reflexes and sensation below the injury level, distinct from the hemodynamic instability of neurogenic shock.
Sympathetic tone — The continuous baseline activity of the sympathetic nervous system maintaining vascular tone and heart rate; lost in neurogenic shock.
Parasympathetic dominance — Unchecked vagal activity after sympathetic disruption, leading to bradycardia and vasodilation in neurogenic shock.
Secondary injury — The cascade of cellular and vascular events after primary spinal cord trauma that worsens damage, exacerbated by hypotension.