About
Circulatory shock related to parasympathetic stimulation. Can occur as a result of spinal injury or neurologic trauma.
Assess
Hypotension, bradycardia, warm dry extremities
Complications
Blood clots, multi-organ dysfunction syndrome, cardiac or respiratory arrest, death
Diagnosis
Risk for injury related to trauma and damage to internal organs.
Goals
The client will remain free from injury.
Interventions
- Assess and monitor vital signs, cbc, telemetry, pulse-oximetry.
- Immobilize, if spinal cord injury.
- Maintain head of bed at least 30 degrees after spinal or epidural anesthesia.
- Apply antiembolism stockings to prevent DVT.
- Administer prophylactic heparin or low molecular weight heparin to prevent DVT.
- Perform passive range of motion for the client immobilized.
- Assess and monitor lower extremities for positive warmth and adequate circulation.
- Implement safety precautions to prevent injury.
- Monitor for evidence of internal bleeding.
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