A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A. Unequal pupil size
B. Decreasing systolic blood pressure
C. Tachycardia
D. Decreasing body temperature
Correct Answer: A. Unequal pupil size
Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma.
Option B: Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. Cerebral autoregulation is the process by which cerebral blood flow varies to maintain adequate cerebral perfusion. When the MAP is elevated, vasoconstriction occurs to limit blood flow and maintain cerebral perfusion. However, if a patient is hypotensive, cerebral vasculature can dilate to increase blood flow and maintain CPP.
Option C: It increases the pressure on the vagus nerve, which produces bradycardia. High blood pressure causes reflex bradycardia and brain stem compromise affecting respiration. Ultimately the contents of the cranium are displaced downwards due to the high ICP, causing a phenomenon known as herniation which can be potentially fatal.
Option D: It causes an increase in body temperature from hypothalamic damage. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP.
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