CASE STUDY QUESTIONS

1. Acute Intracranial Problems:
Case Study - Head Injury
The paramedics found D.M. lying on the side of the road. He apparently lost control of his
motorcycle and hit a car. D.M. appeared very dazed but was able to speak his name and
address. He does not remember what happened and is not oriented to time or place.
The paramedics put a cervical collar on as a precaution until his neck is cleared of any
injuries. They also started an IV and have been infusing D5W at a keep-open rate. His
family has been notified, and his wife is on the way to the hospital.

2. Vital signs were taken right before he was brought into
the emergency department. His BP was 118/72, his
heart rate was 68, and his respiratory rate was 16.
His lungs were clear and he was in normal sinus
rhythm on the monitor.

3. Brain Components

4. Cerebral Edema
Brain tissue edema can also affect ICP:
Types: vasogenic, cytotoxic, and
interstitial.

5. “I have a terrible headache and feel sick to my stomach.
Maybe it’s a 10… I just don’t know.
Question: Would the nurse give pain medication?

6. Continued assessment-2
Nurse asks patient to look at her. “Can you hear
me?” His response is not understandable.
When painful stimulus is applied, he withdraws
his arm, and opens his eyes. He groans.

7. Glasgow Coma Scale
• What would you give this patient based on the latest
assessment findings following the change in his LOC?

8. Deteriorating Condition
The right side of his head is swollen and boggy.
He has bruising and ecchymosis behind his ear.
He opens eyes to painful stimuli (pressing on
sternum). He has clear drainage from his ear.
What could this indicate?

9. Battles Sign/Halo Sign

10. Early, Moderate, Late Signs of Increased ICP
Early: Decreased LOC
Moderate: H/A, sudden
vomiting without nausea
Late: Irregular respirations such as Cheyne Stokes, eyes with pupils fixed, dilated or
unequal. Normal is 2-6. Doll’s eyes + is normal. Babinski Reflex +: toes fan out when
stroked
Very Late and Deadly: Cushing's triad: widening of PP, decreased HR, deceased
respirations (irregular)
Very Late: Seizures, coma, abnormal posturing; decorticate and decerebrate.

11. Question: What are other signs of
increased ICP?
A. Altered respiratory pattern
B. Dilation of the ipsilateral pupil with sluggish or no response to light
C. Increased systolic pressure
D. Contralateral hemiparesis
E. Decreasing heart rate
F. Vomiting
G. Weak, thready pulse
H. Change in level of consciousness
I. Blurred or double vision

12. What is a priority for the nurse to
implement immediately?
A. apply oxygen via nasal cannula.
B. position the patient with his head elevated.
C. call the radiology department for a stat skull x-
ray.
D. Call HCP for intubation.

13. NCLEX Question:
A. Lower the HOB to 20 degrees.
B. B. Get MRI stat
C. C. Give atropine IV
D. D. Get C-Spine and CT
A client is found lying on the floor with bleeding at
the back of the head. HR is 45, BP is 220/88. What
is first action by the nurse?

14. NCLEX Question
A. Grips are equal and strong.
B. Toes fan out when the sole is stoked.
C. Eyes move in opposite direction when
patient’s head is turned from side to side.
D. Extremities contract to the core
E. Pupils are fixed at 8 mm.
F. LOC stays the same, without changes.
The client has sustained a head injury. Which of the
following signs are positive (not deteriorating)
assessment findings? (SATA)

15. A linear skull fracture and subdural hematoma is
evident from CT and skull xrays.

16. Matching
A. Administration of 100%
oxygen
B. Elevation of head of bed to 30
degrees
C. Endotracheal intubation and
mechanical ventilation
1. Maintains airway and ventilation
2. Ensures adequate oxygenation to
support brain function
3. Promotes venous drainage from
the brain
What interventions go with
rationales for reducing ICP?

17. HCP Provides Plan
What is needed to relieve pressure on the
brain?

18. Initial Collaborative Interventions

19. Post OP Orders:
•ICP monitor
•Ventricular catheter
•Arterial catheter
•Cardiac monitoring
•ET tube with mechanical ventilation
•Head dressing
•NS at 75 mL/hr
•NG tube to suction
•Measure ICP hourly
•HOB elevate 30-45 degrees

20. ICP
Brain, blood, CSF must stay balanced to keep ICP WNL
Influencing factors: arterial and venous pressure, intraabdominal and intrathoracic pressure, posture, temperature and
blood gases especially CO2.
ICP: 5-15; > 20 is abnormal
CPP: amount of pressure needed to maintain adequate brain blood flow;
CPP = MAP – ICP
Normal: 60-100
Less than 50 = ischemia and tissue death
Mean arterial pressure (MAP): 70 is lower limit before symptoms develop (syncope, blurred vision) and 150 is upper
limit (severe vasoconstriction); see page 1301 in Lewis
PaCO2 increases leads to vasodilation and increased CBF (cranial blood flow), decreased PaCO2 leads to
vasoconstriction and decrease CBF. PaO2 < 50 mm Hg leads to dilation and increases CBF. So want to keep PaO2 at
or greater than 100. See pg 1302.
ICP

21. Positioning the Drainage Bag and
Ventricular Reference Point

22. Positioning the ICP
Drainage System
Question: You review the hospital's procedure
for draining cerebrospinal fluid (CSF) via the
external ventricular drain in case D.M.'s ICP
increases to the point of needing acute
intervention. Upon review of the procedure,
you identify that the drip chamber and
drainage bag should be placed at the level of
the patient's ventricular reference point,
approximating the foramen of Monroe. A
reference point for this foramen is
the _______________ of the ear.

23. Clinical Manifestations: Increased ICP
• Change in LOC – most sensitive
(subtle to coma)
• VS change: Example
8 AM: 150/86, P-84, R-14
10 AM: 166/74, P-54, RR-10
to16
• Ocular: Optic II, Oculomotor III,
trochlear IV, abducens VI
• Motor: contralateral hemiparesis or
hemiplegia; posturing
• Headache: Pain at night or
morning is worse; straining
increases pain.
• Vomiting: unexpected, projectile
w/o nausea preceding.

24. Cranial Nerves

25. Assessment Findings
• Patient Data: C/o increasing headache. Drowsy,
confused. Ptosis of the left eye and weakness on the right
side.
• How would you assess for drift with the patient in bed?

26. Decerebrate and Decorticate Postures

27. Babinski Reflex
http://youtu.be/ZFu7bdbnZx8

28. Post-op Craniotomy
What 10 interventions are in place to
facilitate monitoring and recovery?

29. Post-Op
The patient returns from surgery with a ventriculostomy.

30. ICP Measurements
The first ICP measurement is 10 mm Hg. Your first action
should be to do which of the following?
A. Document findings and continue with planned care.
B. Notify the physician of the elevated ICP.
C. Lower the HOB to increase cranial perfusion pressure.
D. Increase the elevation of the HOB from 30 to 45
degrees.

31. Ventriculostomy for ICP
Keep SBP 100-160 and CPP > 60 mm Hg
Normal CPP is 60-100 (Lewis, pg. 1301)
If BP 120/70 and ICP is 20, what is CPP?
If CPP is not normal, what interventions would you
consider?

32. Which Factors Lead to ^ ICP?
A. Coughing and sneezing.
B. Deep breathing
C. Endotracheal suctioning
D. Extreme hip and neck flexion
E. Fear and anxiety
F. Head of bed at 30 degrees.
G. Lateral positioning
H. PaCO2 of 52 mm Hg
I. PaO2 of 80 mm Hg
J. Pain

33. Delegating Activities
Which of the following activities could you delegate to an
unlicensed assistive personnel?
A. assess the ICP readings on another stable post op
patient.
B. Record intake and output on a post-op patient.
C. Teach another patient's family about the plan of care for
the day.
D. Evaluate the effect of an antianxiety agent on a patient
with a CVA.

34. Medications
Which of the following medications may be appropriate to
give this patient and why? (Select all that apply)
A. ranitidine (Zantac), famotidine (Pepcid)
B. mannitol (Osmitrol)
C. phenytoin (Dilantin)
D. D5W IV fluid
E. D5/1/4 NS IV fluid
F. Desmopressin (DDAVP ) or vasopressin (Pitressin)

35. Diabetes Insipidus

36. Labs and Nursing Interventions
Lab results:
Na+ 140 mEq/L , K+ 4.6 mEq/L , Cl- 100 mEq/L , WBCs
17,000/µL, Hgb 13.9 g/dL , and Hct 40%.
ABGs: pH 7.43, PaO2 98 mm Hg, PaCO2 35 mm Hg, HCO3
23 mEq/L, SaO2 98%.
Based on these results, you would notify the physician
and do which of the following?
A. Ask for IV solution change.
B. Ask for drugs to lower ICP
C. Ask to decrease the RR and volume on the ventilator
D. Check the site and odor of head dressings.

37. How Does the Nurse Interact with
Family?

38. What response should you give when
the wife asks specific questions about
his recovery?
A. Unfortunately, patients who have this type of brain trauma will always have
some degree of neurologic impairment.
B. He will require long-term rehabilitation for motor and sensory losses
before he can function normally and return home.
C. He will be expected to show gradual, continuous improvement in
neurologic function until he has returned to normal status.
D. Recovery is very individualized and may continue for 6 months or longer
before a plateau is reached and a prognosis for recovery can be made.

39. Question:
What assessment finding requires immediate intervention
if found while a patient is receiving Mannitol?*
A. An ICP of 10 mmHg
B. Crackles throughout lung fields
C. BP 110/72
D. Patient complains of dry mouth and thirst

40. Question
Which of the following is contraindicated in
a patient with increased ICP?
A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications

41. Question:
During the eye assessment of a patient with increased
ICP, you need to assess the oculocephalic reflex. If the
patient has brain stem damage what response will you
find?*
A. The eyes will roll down as the head is moved side to
side.
B. The eyes will move in the opposite direction as the
head is moved side to side.
C. The eyes will roll back as the head is moved side to
side.
D. The eyes will be in a fixed mid-line position as the
head is moved side to side.

42. Question
You’re maintaining an external ventricular drain. The ICP
readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg

43. The End