Assessment
A patient with a traumatic brain injury becomes increasingly restless and agitated. What is the most likely underlying cause of this change?
Early sign of increased intracranial pressure due to decreased cerebral perfusion and rising ICP.
A patient with ICP of 22 mm Hg is restless and attempting to climb out of bed. What is the priority nursing action?
Reduce stimulation and prevent agitation (sedation/restraints if necessary) to decrease ICP.
What is the mechanism of action of Mannitol in treating increased ICP?
Creates osmotic gradient that pulls fluid from brain tissue into the bloodstream.
Why are seizures dangerous in a patient with increased ICP?
They increase cerebral metabolic demand and oxygen consumption, worsening ICP.
Why should the head of the bed be elevated in patients with increased ICP?
Why should the head of the bed be elevated in patients with increased ICP?
A patient’s ICP rises from 15 to 22 mm Hg. What additional clinical finding would confirm worsening neurologic status?
Decreasing level of consciousness (most sensitive indicator of worsening ICP).
Why should suctioning be limited in a patient with increased ICP?
Suctioning increases intrathoracic pressure, which decreases venous return from the brain and raises ICP.
Why must serum osmolality be monitored in patients receiving Mannitol?
To prevent excessive dehydration and kidney injury from osmotic diuresis.
What is the risk of giving excessive IV fluids to a patient with TBI?
Worsening cerebral edema and increased ICP.
Why should the patient’s neck be kept in neutral alignment?
Prevents obstruction of jugular venous outflow, which would increase ICP
A patient develops unilateral pupil dilation and sluggish reaction to light. What complication is most likely occurring?
Brain herniation (specifically uncal herniation compressing CN III).
A provider orders 0.45% sodium chloride for a TBI patient. What is the nurse’s best action?
Question the order because hypotonic fluids worsen cerebral edema and increase ICP.
To prevent excessive dehydration and kidney injury from osmotic diuresis.
Maintain cerebral perfusion pressure (CPP) by increasing systemic blood pressure.
A patient with TBI begins vomiting suddenly without nausea. What does this indicate?
A patient with TBI begins vomiting suddenly without nausea. What does this indicate?
A nurse clusters care for a patient with increased ICP. Why is this problematic?
A nurse clusters care for a patient with increased ICP. Why is this problematic?
A TBI patient has BP 180/60, HR 48, irregular respirations. What is this pattern called and what does it indicate?
Cushing’s triad; indicates late-stage increased ICP and impending brain herniation.
A patient with TBI is receiving 3% Sodium Chloride. What is the primary therapeutic goal?
Pull fluid out of brain cells to reduce cerebral edema and decrease ICP.
Why is Pentobarbital used in severe TBI with refractory ICP?
Induces coma to decrease cerebral metabolic demand and reduce ICP.
What is the consequence of prolonged elevated ICP on cerebral perfusion?
Decreased CPP leading to ischemia and brain tissue death.
Why is hyperventilation used cautiously in ICP management?
Causes cerebral vasoconstriction, which may reduce blood flow and lead to ischemia.
A patient receiving Mannitol begins to show confusion and crackles in the lungs. What complication is developing?
Fluid overload leading to pulmonary edema due to osmotic fluid shifts.
A patient’s ICP suddenly spikes to 28 mm Hg. Which intervention should the nurse perform FIRST: administer Lorazepam, reposition the patient, or suction the airway?
Reposition the patient (head midline, HOB elevated) to immediately improve venous drainage and reduce ICP
A patient receiving Phenytoin for TBI management — what complication is this preventing?
Seizures, which increase metabolic demand and significantly raise ICP.
If ICP exceeds mean arterial pressure (MAP), what occurs?
If ICP exceeds mean arterial pressure (MAP), what occurs?
A patient’s ICP is 24 mm Hg. The nurse notices the patient is febrile. Why is this concerning?
A patient’s ICP is 24 mm Hg. The nurse notices the patient is febrile. Why is this concerning?