Page 277 - Critical Care Nursing Demystified

262 CRITICAL CARE NURSING DeMYSTIFIED

ANSWERS

CASE STUDY

Continue to assess the widening pulse pressure of the Cushing’s triad, which is a valid indi-
cator of an increase in ICP.
Level of consciousness and responses to verbal questions and commands also need to be
scrupulously observed for signs of improvement or deterioration as they are also clinically
significant of an increase in ICP.
Laboratory analysis, blood work, and arterial blood gases need to be drawn and scrutinized
to establish the patient’s baseline chemistry profile.
Results of diagnostic studies such as a CAT scan will determine the extent of the head
trauma and the relevance of the ICP.
Implement the Glasgow Coma Scale immediately and q 15 minutes, comparing each at-
tached score. Rationale: To determine patient status of motor and verbal responses, and
eye opening.
Maintain a patent airway and oxygenation through proper patient positioning, suctioning
as needed, and mechanical ventilation if required.
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well as side effects. Rationale: Certain medications will prevent seizure activity, while oth-
ers such as steroids will reduce inflammation and cerebral edema and promote cerebral
perfusion.
Assess for onset of secondary injuries or problems such as respiratory or cardiac arrest,
onset of seizure activity, or area of paralysis.
Continue to examine pupillary responses to light and accommodation as well as assessing
the size and shape of the pupils, which could help to identify the site of brain trauma.
Performing reflex and motor response activities will also validate muscle strength and
weaknesses as well as motor neuron tract disease.
Continue to assess for patient’s reactions to external stimuli. Rationale: Reactions will indi-
cate normal and abnormal levels of consciousness.
ICP waveform monitoring system is an effective tool for the nurse to use to ascertain
changes in status of ICP.
Any ventricular drains in use must be assessed for patency and status of continuous or
intermittent drainage.
Implement measures to decrease ICP such as pain control, quiet environment, relief of anxiety,
and proper positioning. Avoid improper flexing of the head, neck, legs, and hips, all of which
will increase intraabdominal and intrathoracic pressure, which in turn will increase ICP.
If possible, determine from the patient’s daughter the name and dosage of the antihyper-
tensive medication that the patient has been taking for 20 years. Also question if there is a
family history of cardiac disease.