Medical Surgical Increased ICP #3

Question

A nurse is caring for a client with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The client is on a ventilator and requires suctioning. Which of the following is a priority when suctioning a client with increased intracranial pressure?

Answers

  1. Suction as needed since the client requires airway clearance.
    • Rationale:

      This answer is not correct because suctioning increases ICP and decreases cerebral perfusion pressure. The client will be at risk for further brain damage with an increase in ICP. If suctioning is needed, suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. Cerebral damage when suctioning is utilized.

  2. Limit suction to every 30 minutes instead of every hour
    • Rationale:

      This answer is not correct because suctioning too often will hasten the risk of increased ICP further. Assessment of the client to identify the need for suction would be indicated. If suction is needed, suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. Cerebral damage when suctioning is utilized.

  3. Limit the suction passes to reduce elevations in ICP.
    • Rationale:

      This answer is correct because the most important nursing interventions with a client with ICP are those that reduce ICP from increasing. Suctioning greatly increases ICP. A sudden increase in pressure can lead to further brain injury, seizure, coma, stroke, or death. If suction is needed, suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. cerebral damage when suctioning is utilized.

  4. Limit suctioning because decreased blood pressure may occur.
    • Rationale:

      This answer is not correct because increased, not decreased blood pressure may occur with suctioning. This is part of the Cushing’s triad that reflects increased ICP. Cushing’s triad signs are opposite of shock symptoms (increased blood pressure, decreased heart rate). Also, the third sign of the triad is widened pulse pressure (difference between systolic blood pressure and diastolic blood pressure) and some sources have the third component as irregular respirations (Cheyne-Stokes breathing). If suction is needed, suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. Cerebral damage when suctioning is utilized.

Overview

Clients with increased ICP are at risk for further elevations of the ICP when suctioning. Increased intracranial pressure (ICP) is a very dangerous condition. It can lead to the worst case scenario of brain herniation and death.

Explanation

Learning Outcomes

Increased intracranial pressure (ICP) is a very dangerous condition. It can lead to the worst case scenario of brain herniation and death. Symptoms associated with ICP are represented in the Cushing’s triad. Some Cushing’s triad signs are opposite of shock symptoms (increased blood pressure, decreased heart rate). Also, the third sign of the triad is widened pulse pressure (difference between systolic blood pressure and diastolic blood pressure) and some sources have the third component as irregular respirations (Cheyne-Stokes breathing). Endotracheal suctioning with severe head injured clients may result in a sudden increase in intracranial pressure and may increase the risk for further brain damage. Suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provide increased oxygen prior to the procedure. Cerebral damage when suctioning is utilized. Endotracheal suctioning is a nursing procedure to clear excess respiratory secretions to decrease pulmonary complications.

Test Taking Tip

The word “limit” is a good neutral word that indicates caution. When it comes to increased ICP and anything with the brain, caution should be instituted in general. Reducing ICP when the question has identified the ICP is increased would be a good idea to consider that answer also.

Video Rationale