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Difficulty: HardPhysiological Adaptation

A client is being managed in the intensive care unit following a severe closed head injury. Over the past hour, the nurse notes a significant change in the client's vital signs: the blood pressure has shifted from 124/82 mmHg to 180/58 mmHg, the heart rate has decreased from 86 to 48 beats/minute, and the respirations have become increasingly irregular with brief periods of apnea. Which of the following is the most appropriate initial nursing action?

  1. A
    Administer a prescribed as-needed intravenous antihypertensive medication to reduce the widening pulse pressure.
  2. B
    Perform deep endotracheal suctioning for 15 seconds to address the irregular respiratory pattern and apnea.
  3. Ensure the head of the bed is elevated to 30 degrees with the client's neck in a neutral, midline position.Answer
  4. D
    Prepare the client and equipment for an immediate lumbar puncture to drain excess cerebrospinal fluid.

Answer

Ensure the head of the bed is elevated to 30 degrees with the client's neck in a neutral, midline position.
The client is exhibiting Cushing's triad (severe systolic hypertension with a widening pulse pressure, bradycardia, and irregular respirations), which is a late and life-threatening physiological sign of severely increased intracranial pressure (ICP) indicating impending brainstem herniation. The immediate priority is to maximize venous outflow from the brain to lower the ICP. Elevating the head of the bed to 30 degrees and keeping the head and neck in a neutral, midline position facilitates jugular venous drainage and is a critical, rapid, independent nursing intervention.

Step-by-Step Solution

1
Analyze the changes in the client's vital signs over the past hour.
The blood pressure shows a widening pulse pressure (systolic increased, diastolic decreased), the heart rate has become severely bradycardic, and the respiratory pattern is irregular.
Identifying these specific physiological trends is necessary to recognize the clinical syndrome developing in a client with a brain injury.
2
Correlate the vital sign trends with the client's traumatic head injury diagnosis.
The combination of severe systolic hypertension with widening pulse pressure, bradycardia, and irregular respirations forms Cushing's triad.
Recognizing Cushing's triad is essential because it is a late, life-threatening sign of severely increased intracranial pressure and impending brainstem herniation.
3
Determine the safest, most immediate nursing priority to address the high intracranial pressure.
Elevating the head of the bed to 30 degrees and keeping the head and neck in a neutral position is selected as the initial action.
This physical positioning mechanically facilitates venous blood drainage from the brain via the jugular veins, which safely and rapidly lowers intracranial pressure without causing further harm.

Key Concept

Cushing's Triad and Increased Intracranial Pressure Management
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Topics

Physiological Adaptation

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