# A nurse is caring for a client with a severe traumatic brain injury who has an intracranial pressure (ICP) monitor in place. The client's ICP reading is 25 mmHg, and the nurse observes irregular respirations and a widening pulse pressure. What is the nurse's priority action?

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> subject: Adult Health

## 문제

A nurse is caring for a client with a severe traumatic brain injury who has an intracranial pressure (ICP) monitor in place. The client's ICP reading is 25 mmHg, and the nurse observes irregular respirations and a widening pulse pressure. What is the nurse's priority action?

## 보기

1. Administer prescribed mannitol 1 g/kg IV bolus immediately
2. Notify the healthcare provider immediately and prepare for emergency intervention **✔ 정답**
3. Elevate the head of the bed to 45 degrees and hyperventilate the client
4. Perform neurological assessments every 15 minutes and document findings

**정답: 2**

## 해설

The client shows signs of severely increased ICP (Cushing's triad), a neurological emergency requiring immediate physician notification and preparation for interventions like surgical decompression. Other options are not the priority as they may delay emergency response.

## 심화 해설

Clinical Presentation Analysis

The client exhibits a classic and ominous clinical triad indicating severely elevated intracranial pressure (ICP) and impending brain herniation. The ICP reading of 25 mmHg significantly exceeds the normal threshold of < 15 mmHg and surpasses the critical treatment trigger of 20 mmHg. This finding, combined with irregular respirations (Cushing's triad) and a widening pulse pressure (the difference between systolic and diastolic blood pressure), signals that cerebral autoregulation is failing and the brainstem is under direct compressive threat.

Priority Determination Using the Nursing Process

In an emergent neurological crisis, the priority action is not an independent nursing intervention but immediate communication to activate a higher level of care. While all options contain elements of appropriate care, the sequence is critical. The nurse must first notify the healthcare provider to obtain emergency orders and mobilize the interdisciplinary team for a potential escalation of therapy, which may include emergent surgical decompression. The foundational principle of intracranial dynamics supports this: cerebral perfusion pressure (CPP) is calculated as mean arterial pressure (MAP) minus ICP. An ICP of 25 mmHg critically reduces CPP, leading to cerebral ischemia. The optimization of cerebral perfusion through individualized hemodynamic strategies is a relevant strategy in critical care, and the clinical signs here indicate that the current hemodynamic state is decompensating [1].

Analysis of Incorrect Options

- Option 1: Administering mannitol is a standard medical intervention for elevated ICP. However, as an osmotic diuretic, it requires a provider’s prescription. The nurse cannot independently administer this high-alert medication without an order, making notification the prerequisite step.

- Option 3: Elevating the head of the bed to 45 degrees may be excessive and can paradoxically increase ICP by kinking the neck and reducing cerebral venous outflow; 30 degrees is the standard. Furthermore, routine prophylactic hyperventilation is no longer standard care. Aggressive hyperventilation to a PaCO₂ of 25-30 mmHg causes cerebral vasoconstriction, which can critically reduce cerebral blood flow and worsen ischemia. It is reserved as a temporary, physician-directed bridge to definitive treatment.

- Option 4: Performing neurological assessments is a core nursing function, but in the presence of Cushing’s triad and a critically high ICP, the situation has moved beyond the assessment phase. Delaying action to perform and document assessments while the client is actively herniating represents a failure to act on recognized critical cues.

The presence of irregular respirations and a widening pulse pressure in the context of a known severe traumatic brain injury and an ICP of 25 mmHg represents a preterminal state. The nurse’s immediate priority is to activate the emergency response system by notifying the provider to prevent irreversible brainstem herniation [1].References (research sources)

- [1]Impact of hemodynamic management guided by intracranial compliance on the outcome of critically ill patients - preliminary results and exploratory economic evaluation.Research articleMoreira CEN, Padovesi CM, Sales VVT, Holdack PJF, Furlan MMD, Tavares MS, Carnielo MT, Bianco AM. (2026) · DOI: 10.1186/s12962-026-00721-4

## 임상 시나리오

Recognizing Impending Brain HerniationCushing's Triad and Emergency Response
The combination of ICP > 20 mmHg, irregular respirations, and widening pulse pressure constitutes a late, critical sign of rising intracranial pressure known as Cushing's triad. This indicates failing cerebral autoregulation and direct brainstem compression.

The nurse's immediate priority is to notify the healthcare provider to obtain emergency orders and mobilize the interdisciplinary team. Interventions like mannitol administration or hyperventilation require a provider's order and should not delay this initial step.

CautionDo not delay notification to perform detailed neurological assessments. Prophylactic hyperventilation to a PaCO2 < 35 mmHg is avoided due to the risk of cerebral ischemia. Head of bed elevation is typically maintained at 30 degrees.

## 핵심 개념

- **Cushing's Triad** — A classic late sign of increased intracranial pressure (ICP) consisting of bradycardia, irregular respirations, and widening pulse pressure.
- **Cerebral Perfusion Pressure (CPP)** — The pressure gradient driving cerebral blood flow, calculated as Mean Arterial Pressure (MAP) minus ICP; normal is 60-70 mmHg.
- **Widening Pulse Pressure** — An increasing difference between systolic and diastolic blood pressure, indicating rising ICP and impending brainstem herniation.
- **Intracranial Pressure (ICP)** — The pressure inside the skull; normal is 5-15 mmHg, with sustained readings above 20 mmHg requiring intervention.
- **Brain Herniation** — A life-threatening shift of brain tissue from its normal compartment due to high pressure, compressing the brainstem.

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