Neurogenic Shock NCLEX Review
(SNS)
What’s neurogenic shock?
This type of shock leads to the inability of
the sympathetic nervous system to stimulate
nerve impulses, which causes hemodynamic
problems. This leads to a decrease in tissue
perfusion where the cells that make up our organs
and tissue don’t receive enough oxygen. Hence,
signs and symptoms of shock occur.
Neurogenic shock is a type of distributive
shock (anaphylactic and septic shock are the other
types of distributive shock). This means that the
vessels that deliver blood flow to the cells have an
issue with distributing  that blood flow.
In neurogenic shock, it’s due to massive vasodilation
because the sympathetic nervous system has lost
the ability to stimulate nerves that control vessel
vasomotor tone (this is the ability to regulate the
diameter of the vessels discussed in detail below).
What can cause  neurogenic shock?
 Spinal cord injuries that are located at the
cervical or upper thoracic locations (above
T6)
 Drugs that affect the autonomic and
sympathetic nervous system
 Spinal anesthesia
Neurogenic shock is sometimes referred to
as vasogenic shock.
Pathophysiology of Neurogenic Shock
Let’s talk about what is occurring in neurogenic
shock, but first let’s do a quick review of the
autonomic nervous system.
The autonomic nervous system controls the
functions we cannot consciously control like our
heart rate, digestion, rate of breathing, pupil
response, etc. It is divided into two systems called
the:
Sympathetic Nervous System 
and Parasympathetic Nervous System (PSNS)
The parasympathetic nervous system is known
as the “rest and digest” system. It helps us relax by
decreasing our heart rate and allows us to digest
food, among other functions.
The sympathetic nervous system is the “keep
you alive or fight or flight” system! It increases the
heart rate, blood pressure, dilates your pupils for
better vision etc. Therefore, a HUGE role it plays is
that it controls VASOMOTOR TONE. This means that
the SNS regulates the diameter of our vessels. It will
cause our vessels to constrict or dilate as needed,
depending on the signals it receives from the body.
Now, it’s very important to note that the PSNS and
SNS are always balancing each other out to
keep things regulate in our body. For example,
if the SNS had to kick in to save your life, eventually
it would have to slow down and this is where the
PSNS system would help. Therefore, if one system is
not working (as the case with neurogenic shock…the
SNS is malfunctioning), the other system will be
UNOPPOSED and in a sense take over, which is why
many patients with neurogenic shock will
have bradycardia.
How does the sympathetic nervous system regulate
the diameter of our vessels? The nerve fibers of the
sympathetic nervous system branch out and hang
out on the layers of the vessels. When nerve signals
are fired, it will cause the neurotransmitters
epinephrine and norepinephrine to be released.
These neurotransmitters will cause the vessel to
constrict (narrow). However, if there is a low level of
nerve firing or NO firing, these neurotransmitters are
NOT released, so the vessel just relaxes hence
dilates. This is the problem with neurogenic
shock. The nerves are not being stimulated, so
they are relaxed.
This causes major problems!
Why? Dilated vessels affect the blood pressure.
When vasomotor tone is lost, vessel dilation occurs
and this lowers systemic vascular resistance
(SVR), which causes a major decrease in blood
pressure (hypotension). Due to the decreased SVR
and low blood pressure, blood pooling will occur in
the vessels. This will DECREASE the amount of blood
draining back to the heart (remember there is not
pressure/resistance helping to push it back so it just
hangs out away from the heart).
What does this leave the heart to pump? Hardly
anything at all! This will cause a DECREASE in tissue
perfusion.
In addition, this blood pooling will lead to a risk
of deep vein thrombosis (DVT) development and
lower the body core temperature (hypothermia).
Why hypothermia? The blood is just sitting in the
extremities cooling down and not returning to the
core body to be warmed. These patients will
have warm/dry extremities but a cold body.
Why does this lead to a decrease in tissue
perfusion? There is venous pooling of blood and not
much blood will be flowing back to the heart
because there isn’t any resistance making it go
back.  This will decrease cardiac preload (the
amount the ventricle stretch at the end of
diastole/filling phase) and cardiac
afterload (resistance the ventricles must overcome
to pump blood out of the heart and this is due to the
decrease in SVR).
Remember we discussed in our lecture on cardiac
output that cardiac preload and afterload play a
huge role with cardiac output because they affect
stroke volume (the amount of blood the ventricle
pumps with each BEAT), which affects cardiac
output. CO is calculated by:
CO = Heart Rate (HR) x Stroke Volume (SV)
Cardiac output is the amount of blood the heart
pumps per minute. When CO falls, so does the
amount of blood that is rich in oxygen that flows to
the cells that make up our tissues and organs. If
cells don’t receive enough oxygen they start to die,
and the patient starts to experience the classic signs
and symptoms of shock.
Also, hypothermia can occur due to the body’s
inability to regulate the body temperature because
of hypothalamus dysfunction. This is further
complicated by the peripheral vasodilation and
pooling of blood in the extremities (as discussed
above). This will lead to heat loss because the blood
isn’t returning back to the body to keep it warm. So,
extremities will be warm and dry, but the body will
be cold (poikilothermic: loses the ability to regular
core body temperature).
Bradycardia will occur too! The heart rate is
controlled by both the sympathetic and
parasympathetic nervous system. SNS increases the
heart rate and PSNS works to decrease the heat
rate. Therefore, they are both balancing out the
heart rate. If we lose the function of the SNS, the
PSNS will be unopposed and bradycardia will occur.
Recap of the pathophysiology and the signs
and symptoms in neurogenic shock:
The major signs and symptoms you will see with
neurogenic shock are
hypotension, bradycardia, hypothermia, warm/dry
extremities but cold body
Patho: One major function that is lost in neurogenic
shock is the ability to regulate the diameter of the
blood vessels. Therefore, the vessels are just relaxed
(dilated). This will decrease systemic vascular
resistance and hypotension will occur. Also, since the
SNS isn’t working very well (which helps increase
our heart rate) the parasympathetic system will take
over (which decreases the heart rate)
so bradycardia will occur. Hypothermia occurs
because of hypothalamus dysfunction and is further
complicated by blood pooling in the extremities
(remember this blood is sitting there and cooling off
because it is not going back to the body). Warm/dry
extremities can be found due to dilated vessels
causing the blood to pool in the extremities.
These signs and symptoms are slightly different than
the other types of shock we have covered, especially
in the early stages of shock.
WHY? Remember during the early stages of shock
in the other types of shock, the sympathetic nervous
system kicks into gear to help “save” the body by
causing vasoconstriction with the release of
norepinephrine and epinephrine. This would increase
the heart rate, blood pressure (in hope of increasing
CO) etc. However, in neurogenic shock, this doesn’t
occur because the body has lost the ability to
stimulate the sympathetic nervous system due to
this injury.
Neurogenic shock is different from spinal shock
because neurogenic shock causes hemodynamic
changes with hypotension and bradycardia related to
its injury. Whereas, spinal shock causes changes
with sensation, motor, and reflexes.
Neurogenic Shock Nursing Interventions and
Treatments
Goal: Manage patient’s ABCS (Airway, Breathing,
Circulation & Spine)
Protect the spine: Keep spine immobilized (don’t
want to cause any more damage and decrease
perfusion to the spine) Example: cervical collar, log
rolling patient during transport, using a backboard
May need intubation and mechanical ventilation if
respiratory failure present (respiratory issues can
occur depending on the location of the injury)
Maintain tissue perfusion: want MAP to be 85-
90 mmHg. This helps maintain perfusion to
organs, specifically the spine. (Dave and Cho,
2018)
How?
Intravenous fluids: crystalloids (fills the dilated
vessels, increases venous return to the heart which
will increase cardiac preload and cardiac output)
 IVFs are used with caution because the
patient usually has a normal blood volume.
Therefore, monitor for fluid overload.
 Example: dyspnea, crackles, swelling,
increased CVP or PAWP
 If no response with IVFs, then vasopressors
may be used.
Vasopressors: causes vasoconstriction (narrowing of
vessels) which will increase SVR and increase blood
pressure and cardiac output
 Positive
inotropes: Dopamine (vasoconstriction and
increases heart rate)
Bradycardia? Atropine
 blocks the parasympathetic effects on the
heart
 If severe, the patient may need temporary
pacing
Rewarming devices for hypothermia: slowing with
rewarming and monitor body core temperature
Foley (some patients lose bladder function) Want
urinary output 30 cc/hr or higher this tells us how
well the kidneys are being perfused
Prevent DVT (blood is pooling) apply compression
stockings, ROM (range-of-motion exercises),
anticoagulants per MD order
 Avoid crossing patient legs or placing pillow
under patient’s knees because this further
compromises circulation

Neurogenic Shock NCLEX Questions
1.      You’re working on a neuro unit. Which of your
patients below are at risk for developing neurogenic
shock? Select all that apply:
A.     A 36-year-old with a spinal cord injury at L4.
B.     A 42-year-old who has spinal anesthesia.
C.     A 25-year-old with a spinal cord injury above
T6.
D.     A 55-year-old patient who is reporting seeing
green halos while taking Digoxin.
The answers are B and C. Any patient who has had
a cervical or upper thoracic (above T6) spinal cord
injury, receiving spinal anesthesia, or taking drugs
that affect the autonomic or sympathetic nervous
system is at risk for developing neurogenic shock.
2.      True or False: The parasympathetic nervous
system loses the ability to stimulate nerve impulses
in patients who are experiencing neurogenic shock.
This leads to hemodynamic changes.
Answer: FALSE the statement should say: The
sympathetic (NOT parasympathetic) nervous system
loses the ability to stimulate nerve impulses in
patients who are experiencing neurogenic shock.
This leads to hemodynamic changes.
3.      A 42-year-old male patient is admitted with a
spinal cord injury. The patient is experiencing severe
hypotension and bradycardia. The patient is
diagnosed with neurogenic shock. Why is
hypotension occurring in this patient with neurogenic
shock?
A.     The patient has an increased systemic vascular
resistance.  This increases preload and decreases
afterload, which will cause severe hypotension.
B.     The patient’s autonomic nervous system has
lost the ability to regulate the diameter of the blood
vessels and vasodilation is occurring.
C.     The patient’s parasympathetic nervous system
is being unopposed by the sympathetic nervous
system, which leads to severe hypotension.
D.     The increase in capillary permeability has
depleted the fluid volume in the intravascular
system, which has led to severe hypotension.
The answer is B. The sympathetic nervous system
(which is a division of the autonomic nervous
system) is unable to stimulate the nerves that
regulate the diameter of the blood vessels (there’s a
loss of vasomotor tone). So, now the vessels are
relaxed and this causes massive vasodilation.
Systemic vascular resistance will decrease and
hypotension will occur.
4.      You receive a patient in the ER who has
sustained a cervical spinal cord injury. You know this
patient is at risk for neurogenic shock. What
hallmark signs and symptoms, if experienced by this
patient, would indicate the patient is experiencing
neurogenic shock? Select all that apply:
A.     Blood pressure 69/38
B.     Heart rate 170 bpm
C.     Blood pressure 250/120
D.     Heart rate 29
E.      Warm and dry extremities
F.      Cool and clammy extremities
G.     Temperature 104.9 ‘F
H.     Temperature 95 ‘F
The answers are A, D, E, and H. Hallmark signs and
symptoms of neurogenic shock are: hypotension,
bradycardia, hypothermia, warm/dry extremities
(this is due to the vasodilation and blood pooling
and will be found in the extremities).
5.      In neurogenic shock, a patient will experience
a decrease in tissue perfusion. This deprives the
cells of oxygen that make up the tissues and organs.
Select all the mechanisms, in regards to
pathophysiology, of why this is occurring:
A.     Loss of vasomotor tone
B.     Increase systemic vascular resistance
C.     Decrease in cardiac preload
D.     Increase in cardiac afterload
E.      Decrease in venous blood return to the heart
F.      Venous blood pooling in the extremities
The answers are A, C, E, and F. Massive vasodilation
is occurring in the body and this is due to the loss of
vasomotor tone (remember the sympathetic nervous
system loses its ability to stimulate nerves that
regular the diameter of vessels….so vessels are
relaxed). This will DECREASE (NOT increase)
systemic vascular resistance (which will decrease
cardiac afterload) and the blood pressure will fall.
Furthermore, there is pooling of venous blood in the
extremities because there isn’t any pressure to push
it back to the heart. This will cause a decrease in
venous blood return to the heart. When this occurs
it will decrease cardiac preload (the amount the
ventricle stretch at the end of diastole). All of this
together will decrease the amount of blood the heart
can pump per minute….hence the cardiac output
and shock will occur.
6.      You’re providing care to a patient experiencing
neurogenic shock due to an injury at T4. As the
nurse, you know which of the following is a patient
safety priority?
A.     Keeping the head of the bed greater than 45
degrees at all times.
B.     Repositioning the patient every thirty minutes.
C.     Keeping the patient’s spine immobilized.
D.     Avoiding log-rolling the patient during
transport.
The answer is C. It is very important when a patient
has a spinal cord injury to keep the spine protected.
The nurse wants to prevent further damage or
perfusion issues to the spinal cord. Therefore, the
patient’s spine should be immobilized. Example:
usage of cervical collar, log-rolling, usage of a
backboard.
7.      A patient in neurogenic shock is ordered
intravenous fluids due to severe hypotension. During
administration of the fluids the nurse will monitor
the patient closely and immediately report?
A.     Increase in blood pressure
B.     High central venous pressure (CVP) and
pulmonary artery wedge pressure (PAWP)
C.     Urinary output of 300 mL in the past 5 hours
D.     Mean arterial pressure (MAP) 85 mmHg
The answer is B. Option B would indicate the patient
is in fluid volume overload. Remember that patients
in neurogenic shock usually have a normal blood
volume. If fluids are ordered to help increase the
blood pressure, they should be used with extreme
caution because fluid overload can occur. An
increase in the CVP and PAWP would indicate this.
These pressures show the filling pressure in the
heart.
B.     Mean arterial pressure (MAP) 90 mmHg
C.     Serum lactate 6 mmol/L
D.      Blood pH 7.20
The answer is B. A MAP of 85-90 mmHg will help
maintain tissue perfusion and indicates the
vasopressor is working to maintain tissue perfusion.
It does this by causing vasoconstriction. Options A,
C, and D would indicate tissue perfusion is
decreased.
10.   You’re developing a nursing plan of care for a
patient with neurogenic shock. As the nurse, you
know that due to venous blood pooling from
vasodilation a deep vein thrombosis can occur in this
type of shock. A patient goal is that the patient will
be free from the development of a deep vein
thrombosis. Select all the nursing interventions
below that can help the patient meet this goal:
A.     Perform range of motion exercises daily.

8.      A patient with neurogenic shock is B.     Place a pillow underneath the patient knees as
experiencing a heart rate of 30 bpm. What needed.
medication does the nurse anticipate will be ordered
by the physician STAT? C.     Administer anticoagulants as scheduled per
physician’s order.
A.     Adenosine
D.     Apply compression stockings daily.
B.     Warfarin
The answers are A, C, and D. Option B would
C.     Atropine impede blood flow and increase the risk of a DVT.
The other options would help prevent a DVT.
D.     Norepinephrine

The answer is C. Atropine will quickly increase the

heart rate and block the effects of the
parasympathetic system on the body. Remember
bradycardia occurs in neurogenic shock because the
sympathetic nervous system (which increases the
heart rate) loses its ability to stimulate nerves. The
sympathetic and parasympathetic systems are, in a
way, balancing each other out when it comes to the
heart rate. The sympathetic system increases it,
while the parasympathetic decreases it. If the
sympathetic system isn’t working the way it should,
it can NOT oppose the parasympathetic
system….which will take over and lead to
bradycardia.

9.      Your patient in neurogenic shock is not

responding to IV fluids. The patient is started on
vasopressors. What option below, if found in your
patient, would indicate the medication is working?

A.     Decreased CVP (central venous pressure)