A nurse is assessing a client with a severe traumatic brain injury and notes a sudden, profound decline in the level of consciousness. The client's vital signs are heart rate 44 beats/min, blood pressure 196/60 mm Hg, and irregular, shallow respirations. The nurse immediately calls out for emergency assistance. Arrange the following subsequent nursing actions in the priority order they should be performed.
- 1Assess airway patency and administer high-flow supplemental oxygen.
- 2Elevate the head of the bed to 30 degrees and ensure neutral neck alignment.
- 3Notify the neurosurgical healthcare provider of the vital sign changes.
- 4Ensure intravenous access and administer a prescribed osmotic diuretic.
- 5Prepare and accompany the client for an emergent computed tomography (CT) scan.
Answer
The correct sequence is: Assess airway/oxygenation, elevate the head of the bed, notify the healthcare provider, administer an osmotic diuretic, and finally prepare for a CT scan.
In any acute neurological crisis involving Cushing's triad (bradycardia, widened pulse pressure/hypertension, and irregular respirations), the client is at imminent risk of brainstem herniation. The nurse must follow the ABCs, prioritizing airway and oxygenation to prevent hypercapnia-induced vasodilation. Next, the nurse performs the immediate independent intervention of elevating the head of the bed and maintaining neutral neck alignment to promote venous drainage. After stabilizing the client with these immediate actions, the nurse notifies the healthcare provider to obtain stat orders. Dependent interventions, such as administering osmotic diuretics (mannitol), are then implemented based on these orders. Finally, once initial medical stabilization is achieved, the client is transported for diagnostic imaging (CT scan) to determine the need for surgical decompression.
Step-by-Step Solution
Key Concept
Prioritization in the management of increased intracranial pressure (Cushing's Triad)
Estimated Time:2m 0s