Medical Surgical Increased ICP #5

Question

A client injured in a motor vehicle accident is transferred to the intensive care unit with a diagnosis of head trauma. The emergency room nurse reports the client has increased intracranial pressure. Which assessment findings are the most important for the nurse to monitor? Select all that apply.

Answers

  1. Urine output
    • Rationale:

      This answer is not correct because urine output is not the most important indicator of increased intracranial pressure associated with head trauma. While urine output and respiratory rate are important, the question is focused on critical indicators associated with increased ICP, such as cerebral perfusion pressure and systolic blood pressure.

  2. Rate of respirations
    • Rationale:

      This answer is not correct because irregular breathing is a result of rising systolic pressure, not the cause. The question is focused on the critical indicators associated with increased intracranial pressure caused by head trauma, such as assessment of perfusion pressure, and systolic blood pressure.

  3. Cerebral perfusion pressure
    • Rationale:

      This answer is correct because the assessment of cerebral perfusion pressure (CPP) is important since it can indicate if the intracranial pressure is increasing or decreasing. Normal cerebral perfusion pressure is imperative to prevent ischemia of brain tissue. The systolic plus diastolic blood pressures are important and necessary in order to monitor mean arterial pressure (MAP). The MAP is necessary to assess since it reflects pressure required for brain perfusion with each cardiac cycle. The ICP and MAP will provide analysis of cerebral perfusion pressure. The increased blood pressure is a reflex to maintain cerebral perfusion pressure. This increase of blood pressure produces reflex bradycardia, which can cause herniation of the brain stem.

  4. Systolic blood pressure
    • Rationale:

      This answer is correct because if the systolic blood pressure is low, blood flow to the brain may be compromised and this can cause decreased CPP. The brain requires a large amount of oxygen to prevent brain injury. The increased blood pressure is a reflex to maintain cerebral perfusion pressure. This increase of blood pressure produces reflex bradycardia, which can cause herniation of the brain stem. Therefore, monitoring the blood pressure can help know if the ICP is further increasing.

  5. Assess for rhinorrhea
    • Rationale:

      This answer is correct because rhinorrhea may indicate drainage of CSF. CSF drainage will increase ICP. CSF presents as clear nasal drainage that separates into rings and is positive for glucose.

Overview

Normal intracranial pressure (ICP) is important to maintain to prevent brain death due to poor cerebral perfusion. The nurse should prioritize monitoring cerebral perfusion pressure and systolic blood pressure.

Explanation

Learning Outcomes

Head trauma can cause increased intracranial pressure (ICP) when cerebrospinal fluid or bleeding from your brain causes increased pressure inside your skull and brain tissue. Signs and symptoms include mental status changes, pupillary changes, headache, increased respiratory rate, seizures, and nausea/vomiting. Nursing interventions include reducing stimuli, elevating head of bed to 30 degrees to reduce arterial pressure while keeping the neck in a neutral position, promoting venous drainage, as well as keeping the client’s body temperature in normal range. It is important to also monitor for volume overload. Treatment options include drainage of cerebrospinal fluid or blood, osmotic or loop diuretics, sedation, and anticonvulsants. Sometimes a craniectomy is also indicated.

Test Taking Tip

Pay attention to phrases in test questions such as “most important” and always utilize the ABCs (airway, breathing, and circulation) of triage when these types of phrases are used.

Video Rationale