ICP & Positioning
his standard position, used for patients with increased ICP, promotes venous drainage and lowers intracranial pressure.
What is elevating the head of the bed to 30 degrees?
This triad of symptoms is the body’s warning that dangerous ICP elevation may lead to herniation.
What is bradycardia, widened pulse pressure, and irregular respirations?
This injury must always be suspected in a patient with a traumatic brain injury until it is ruled out.
What is a cervical spine injury?
An increased PaCO₂ level raises ICP because CO₂ acts as this type of cerebral blood vessel influencer.
What is a vasodilator?
Low urine output, weight gain, and hyponatremia in a TBI patient suggest this condition.
What is SIADH?
Maintaining this alignment prevents jugular vein compression and helps keep ICP from rising.
What is keeping the head and neck midline and neutral?
This classic pattern: loss of consciousness, a lucid interval, then rapid decline, is seen in this type of hematoma.
What is an epidural hematoma?
In autonomic dysreflexia, this first nursing action helps identify the most common trigger.
What is checking the Foley catheter for kinks?
When administering mannitol, this device is needed to verify diuresis and prevent renal complications.
What is a Foley catheter?
High urine output and hypernatremia after TBI is most consistent with this condition.
What is diabetes insipidus?
According to the Monro–Kellie doctrine, this shift helps compensate for rising intracranial pressure.
What is displacement of CSF out of the skull?
A heart rate of 35, BP 180/80, and irregular respirations most likely indicate this condition.
What is increased intracranial pressure?
For a patient with a C1–C4 spinal injury, these two pieces of equipment must always be at the bedside.
What are a bag-mask resuscitator and suction?
This is the most serious complication of an intraventricular catheter.
What is infection?
Concussion, contusion, hematoma, and diffuse axonal injury are all examples of this category of injury.
What are primary brain injuries?
This component of Cushing’s triad reflects a widening difference between systolic and diastolic pressure.
What is widened pulse pressure?
Rapid bleeding caused by a tear in the middle meningeal artery leads to this emergency hematoma.
What is an epidural hematoma?
This type of shock is characterized by both hypotension and bradycardia.
What is neurogenic shock?
A sudden ICP spike in a patient with an intraventricular catheter (IVC) should make the nurse suspect this issue first.
What is catheter obstruction or malfunction?
Preventing hypoxia and hypotension helps prevent this type of brain damage occurring after the initial insult.
What is secondary brain injury?
These three positioning interventions are appropriate for a patient with a basilar skull fracture at risk for increased ICP.
What are head midline, neck neutral, and HOB at 30 degrees?
This is the earliest and most sensitive indicator of neurological decline in head-injured patients.
What is a change in level of consciousness?
This spinal cord syndrome causes ipsilateral loss of motor and proprioception with contralateral loss of pain and temperature.
What is Brown-Sequard syndrome?
A nurse must accompany a deteriorating neuro patient to CT because they are responsible for monitoring this critical function en route.
What is the airway and neurological stability?
Older adults can prevent TBIs by these environmental and personal safety modifications.
What are wearing helmets, removing loose rugs, improving lighting, and using assistive devices?