Group 6A
Traumatic Brain Injury with Increased Intracranial Pressure
Patient Profile
D.G., a 19-year-old male, was brought to the emergency department following a motor vehicle
accident (primary ICP) in which he was the driver. He is transferred to the Neuro-Trauma Intensive
Care Unit with a diagnosis of traumatic brain injury.
Subjective Data
• Multiple family members and friends in the waiting room
• D.G.'s girlfriend died on scene
• Hospital chaplain present
Objective Data
Physical Examination
• Glasgow coma scale 4
o Less than 8!! In coma
• Neurologic Assessment:
o Pupils 4 mm and sluggish
• Normal pupil size in adults varies from 2-4mm.
• Sluggish responses indicate early pressure on CN III.
o Decerebrate posturing
• Extension – stage 4 ICP
o Periorbital ecchymosis
• Raccoon eyes – basilar skull fracture.
• Clear drainage from nares is positive for glucose
o Indicates CSF leaking from the nose; generally associated with a tear in the dura and
subsequent leakage of CSF with basilar skull fracture; confirms the fracture has
traversed the dura; increases risk for meningitis
Diagnostic Studies
• Computed tomography (CT) scan
• Subdural hematoma compressing the ipsilateral (same side as the bleed) ventricle and
causing a midline shift (brain moves away from the side of the lesion, drifting away
from midline)
Collaborative Care
• Admission orders include:
, o Multiple line placements: Arterial monitoring, central venous pressure line,
ventriculostomy, and jugular bulb oximetry
• Arterial monitoring – direct measurement of BP; measures O2 and
CO2 concentration in the blood;
• CVP line – measures pressure of the blood as it returns to the heart
• Ventriculostomy – gold standard; direct pressure within ventricles
• Jugular bulb oximetry – measurement of jugular venous O2 saturation,
indicating total venous brain tissue extraction of oxygen; measure of cerebral
supply/demand (normal 55-75%; <50% impaired cerebral oxygenation)
o Keep cerebral perfusion pressure (CPP) > 70 mm Hg
o Begin standing orders for:
• propofol (Diprivan) – IV anesthetic sedative (pg. 1367)
• midazolam (Versed) – light sedation
• ranitidine (Zantac) – proton pump inhibitor (used to protect stomach
from stress response and increased acid secretion)
• phenytoin (Dilantin) – anti-epileptic (anticonvulsant)
o Continuous cardiac monitoring (monitor for V/S changes, which can indicate worsening
ICP)
o Urinary catheter with strict I&O measurements (monitor for insensible
losses and fluid/electrolyte imbalances)
o Neuro checks every hour (assess for decreased LOC, pupillary dilation, etc.)
o Monitor lab values
• Arterial blood gases analysis guides oxygen therapy and need for
intubation or mechanical ventilation
• Complete blood count detect infection (increased WBCs), glucose, blood loss
• Electrolytes special attention to glucose, sodium, potassium,
magnesium, and osmolality
Discussion Questions
1. Based on the assessment data, what are the nursing priorities for D.G.?
The nursing priorities for D.G. include maintaining a patent airway and adequate oxygenation,
maintaining ICP within normal limits, performing neuro assessments regularly (q. 1 hour) to watch for
changes in LOC; performing motor reflex assessments, monitoring I&Os to keep him normovolemic,
maintaining adequate nutrition, monitoring for VS changes (hypertension, heart rate, temperature), and
oral care (e.g. suctioning) to assist in airway patency. Other priorities include monitoring for DVTs,
elevating the HOB 30 degrees, proper pain management, turning the patient slowly, while avoiding hip
and neck flexion, implementing seizure precautions (e.g. padded bedrails). It is also important to
Traumatic Brain Injury with Increased Intracranial Pressure
Patient Profile
D.G., a 19-year-old male, was brought to the emergency department following a motor vehicle
accident (primary ICP) in which he was the driver. He is transferred to the Neuro-Trauma Intensive
Care Unit with a diagnosis of traumatic brain injury.
Subjective Data
• Multiple family members and friends in the waiting room
• D.G.'s girlfriend died on scene
• Hospital chaplain present
Objective Data
Physical Examination
• Glasgow coma scale 4
o Less than 8!! In coma
• Neurologic Assessment:
o Pupils 4 mm and sluggish
• Normal pupil size in adults varies from 2-4mm.
• Sluggish responses indicate early pressure on CN III.
o Decerebrate posturing
• Extension – stage 4 ICP
o Periorbital ecchymosis
• Raccoon eyes – basilar skull fracture.
• Clear drainage from nares is positive for glucose
o Indicates CSF leaking from the nose; generally associated with a tear in the dura and
subsequent leakage of CSF with basilar skull fracture; confirms the fracture has
traversed the dura; increases risk for meningitis
Diagnostic Studies
• Computed tomography (CT) scan
• Subdural hematoma compressing the ipsilateral (same side as the bleed) ventricle and
causing a midline shift (brain moves away from the side of the lesion, drifting away
from midline)
Collaborative Care
• Admission orders include:
, o Multiple line placements: Arterial monitoring, central venous pressure line,
ventriculostomy, and jugular bulb oximetry
• Arterial monitoring – direct measurement of BP; measures O2 and
CO2 concentration in the blood;
• CVP line – measures pressure of the blood as it returns to the heart
• Ventriculostomy – gold standard; direct pressure within ventricles
• Jugular bulb oximetry – measurement of jugular venous O2 saturation,
indicating total venous brain tissue extraction of oxygen; measure of cerebral
supply/demand (normal 55-75%; <50% impaired cerebral oxygenation)
o Keep cerebral perfusion pressure (CPP) > 70 mm Hg
o Begin standing orders for:
• propofol (Diprivan) – IV anesthetic sedative (pg. 1367)
• midazolam (Versed) – light sedation
• ranitidine (Zantac) – proton pump inhibitor (used to protect stomach
from stress response and increased acid secretion)
• phenytoin (Dilantin) – anti-epileptic (anticonvulsant)
o Continuous cardiac monitoring (monitor for V/S changes, which can indicate worsening
ICP)
o Urinary catheter with strict I&O measurements (monitor for insensible
losses and fluid/electrolyte imbalances)
o Neuro checks every hour (assess for decreased LOC, pupillary dilation, etc.)
o Monitor lab values
• Arterial blood gases analysis guides oxygen therapy and need for
intubation or mechanical ventilation
• Complete blood count detect infection (increased WBCs), glucose, blood loss
• Electrolytes special attention to glucose, sodium, potassium,
magnesium, and osmolality
Discussion Questions
1. Based on the assessment data, what are the nursing priorities for D.G.?
The nursing priorities for D.G. include maintaining a patent airway and adequate oxygenation,
maintaining ICP within normal limits, performing neuro assessments regularly (q. 1 hour) to watch for
changes in LOC; performing motor reflex assessments, monitoring I&Os to keep him normovolemic,
maintaining adequate nutrition, monitoring for VS changes (hypertension, heart rate, temperature), and
oral care (e.g. suctioning) to assist in airway patency. Other priorities include monitoring for DVTs,
elevating the HOB 30 degrees, proper pain management, turning the patient slowly, while avoiding hip
and neck flexion, implementing seizure precautions (e.g. padded bedrails). It is also important to
