The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
Correct Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. 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.
Option A: 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 C: Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure.
Option D: 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.
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