I Have a Headache
A patient with an ICP monitor shows ICP 24 mmHg, MAP 72 mmHg. The nurse identifies the most immediate concern.
What is inadequate cerebral perfusion (CPP = 48 mmHg) requiring intervention?
60-100mmHg
ITP results in decreased platelets due to this process.
What is autoimmune platelet destruction
Loss of motor, sensory, and reflex activity below injury immediately after trauma.
spinal shock
The target MAP for spinal cord perfusion after acute SCI.
What is ≥85 mmHg
A patient post-TBI becomes restless and confused before vital sign changes.
What is early hypoxia or increased ICP
A patient suddenly develops bradycardia, widened pulse pressure, and irregular respirations.
Cushing’s triad indicating impending herniation
Petechiae and mucosal bleeding are classic findings.
thrombocytopenia presentation
A T5 injury places the patient at risk for this hemodynamic complication
neurogenic shock
A patient with MAP 60 mmHg post-SCI requires this intervention.
vasopressor support
CPP=
MAP−ICP
A patient with a subdural hematoma shows gradual LOC decline over hours.
venous bleeding with delayed deterioration
First-line treatment for ITP.
corticosteroids
Flaccid paralysis transitioning to spasticity indicates this phase change.
What is resolution of spinal shock
Hypotension in SCI is most commonly caused by this mechanism.
loss of sympathetic tone
A patient with severe TBI has MAP 80 mmHg and ICP 25 mmHg. The nurse recognizes this CPP value indicates a need for intervention.
CPP of 55 mmHg indicating inadequate cerebral perfusion
Battle’s sign and raccoon eyes indicate this injury type.
What is basilar skull fracture
A key lab finding in ITP.
isolated low platelet count
Injury above C5 most threatens this function
respiratory drive (diaphragm involvement)
Bradycardia + hypotension after SCI suggests this type of shock.
neurogenic shock
A patient’s CPP is 52 mmHg following a TBI. The priority nursing intervention to improve perfusion is:
increase MAP (fluids/vasopressors) or decrease ICP (elevate HOB, sedation, osmotic therapy)
The most sensitive early indicator of neurologic deterioration.
change in level of consciousness
The priority life-saving treatment for TTP.
plasmapheresis
A spinal cord injury patient develops severe hypertension and headache after bladder distention.
autonomic dysreflexia
AVPU scale assesses this component.
What is disability (neurologic status)
A TBI patient becomes hypotensive (MAP drops to 60 mmHg) with ICP 20 mmHg. The nurse identifies the immediate risk.
CPP of 40 mmHg leading to cerebral ischemia