A nurse is caring for a 52-year-old client admitted to the neuro ICU with a confirmed grade III subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm. The client was endovascularly coiled 4 hours ago. Current findings: GCS 12, blood pressure 168/94 mm Hg, heart rate 56 (down from 78), pupils 3 mm reactive, with progressively worsening headache. The external ventricular drain (EVD) is set at 15 cm above the tragus and shows minimal CSF output over the past hour. Which actions should the nurse take? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Post-rupture SAH with new bradycardia (78 to 56), widening pulse pressure (168/94, PP 74), and worsening headache is the Cushing triad — a late and ominous sign of intracranial hypertension. Critical actions: (1) immediate neurosurgeon notification; (2) verify EVD setup — minimal output may signal an occluded line, malposition relative to the tragus reference, or a clamped stopcock; (4) head of bed at 30 degrees with neutral neck optimizes venous return without compromising perfusion; (5) avoid all activities that raise ICP (Valsalva, suctioning without preoxygenation, hip flexion, isometric exercises). HOB flat (option 2) raises ICP. A rapid 1 L crystalloid bolus (option 3) without targeted hemodynamic goals can worsen cerebral edema; SAH protocols use modest euvolemic targets and selective HHH therapy when vasospasm develops.
Cushing Triad — Late ICP Sign Bradycardia + widened pulse pressure + irregular respirations equals imminent herniation. By this stage the intervention window is minutes.
EVD Quick-Check 1. Zero-reference at the tragus (foramen of Monro level) 2. Stopcock open to drainage 3. CSF column oscillates with pulse and respiration 4. Output trends — sudden drop calls for checking tubing kinks, level, occlusion
ICP Hygiene - HOB 30 degrees, neck neutral - No Valsalva (no straining, hip flexion, isometric) - Preoxygenate before brief (less than 10 second) suctioning - Quiet, low-stimulation environment
NCSBN Theme PA — Medical emergency / neurological.
Scenario52-year-old, grade III SAH from ruptured AcomA aneurysm, endovascular coiling 4 hours ago, neuro ICU.
Current Findings- GCS 12- BP 168/94 (PP 74)- HR 56 (down from 78)- Pupils 3 mm reactive- Worsening headache- EVD at 15 cm above tragus, minimal CSF output
Pattern RecognitionBradycardia plus widening pulse pressure plus worsening headache equals Cushing triad / impending herniation. Minimal EVD output prompts a setup, occlusion, and level check.
Subarachnoid Hemorrhage (SAH) — Bleeding into the subarachnoid space, most often from a ruptured cerebral aneurysm. Classic onset: thunderclap worst-headache-of-life. Hunt-Hess and WFNS grading systems guide prognosis. Acute risks: rebleeding (peaks day 0 to 1), hydrocephalus (treated with EVD), vasospasm or delayed cerebral ischemia (peaks day 4 to 14, treated with nimodipine and HHH), seizures, and hyponatremia (CSW).
Cushing triad — Late sign of severely elevated ICP indicating impending brainstem herniation: bradycardia, widening pulse pressure (rising systolic with stable or falling diastolic), and irregular respirations (Cheyne-Stokes or apneustic). Requires immediate intervention — hyperosmolar therapy, hyperventilation bridge, surgical decompression.
External ventricular drain (EVD) — Catheter placed in the lateral ventricle for ICP monitoring and CSF drainage. Zero-referenced to the tragus (level of the foramen of Monro). Adjusted height in cm above the tragus determines the drainage threshold. Always confirm level, stopcock direction, oscillation, and output trend. Sudden zero output may indicate occlusion, a displaced level, or stopcock closed to drainage.