The practical nurse (PN) is monitoring the neurological vital signs of a client with a recently closed head injury. Which vital sign trends indicate increased intracranial pressure (ICP) and should be reported to the charge nurse?
A.
Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension.
B.
Bounding pulse rate, groaning respiratory effort, and elevated blood pressure.
C.
Thready rapid pulse, trembling, perspiration, weakness, and irritability.
D.
Bradycardia, irregular respiratory patterns, widening pulse pressure.
The correct answer and Explanation is :
The correct answer is D. Bradycardia, irregular respiratory patterns, widening pulse pressure.
Explanation:
Increased intracranial pressure (ICP) is a serious condition that can arise from head injuries, and monitoring vital signs is crucial for early detection and management. The trends in vital signs that are indicative of increased ICP include:
- Bradycardia: This is a slower than normal heart rate. When ICP rises, it can lead to a decrease in the heart rate due to increased pressure on the brainstem, which controls heart rate.
- Irregular Respiratory Patterns: Increased ICP can affect the brainstem’s ability to regulate breathing, resulting in abnormal respiratory patterns. This might include Cheyne-Stokes respiration (cyclic pattern of slow and fast breathing) or irregular breathing.
- Widening Pulse Pressure: Pulse pressure is the difference between systolic and diastolic blood pressure. A widening pulse pressure is often seen as ICP increases because the systolic pressure may rise due to compensatory mechanisms, while diastolic pressure might decrease. This widening pulse pressure reflects the body’s attempt to maintain cerebral perfusion pressure (CPP) despite rising ICP.
These signs are part of Cushing’s triad, which is a clinical syndrome associated with severe brain injury and elevated ICP. Cushing’s triad includes bradycardia, hypertension (with widening pulse pressure), and irregular or abnormal respiratory patterns. It is a critical sign that intervention is necessary to prevent further brain damage or deterioration.
In contrast, options A, B, and C describe symptoms that may not directly correlate with increased ICP:
- Option A: Elevated heart rate and hypotension are more commonly associated with shock or other conditions, not specifically with increased ICP.
- Option B: Bounding pulse rate and elevated blood pressure might indicate different types of cardiovascular issues but are not specific markers of increased ICP.
- Option C: Thready pulse, trembling, perspiration, and weakness are nonspecific and can occur in various other conditions, not necessarily indicating elevated ICP.
Therefore, monitoring for bradycardia, irregular respiratory patterns, and widening pulse pressure is critical for identifying increased ICP and should be reported immediately to the charge nurse for further assessment and intervention.