Critical care case study - Intracranial hypertension: Nursing

Nurse Kenji works in the neurological intensive care unit and is caring for Felix, a 22-year-old patient who was admitted after experiencing a blow to the head while playing ice hockey. Nurse Kenji goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Felix’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Kenji recognizes important cues, like Felix’s vital signs which are temperature 100.1 F, or 37.8 C, heart rate 84 beats per minute, respirations 18 breaths per minute, blood pressure 136/72 mmHg, and oxygen saturation 96% on 2 liters of oxygen per nasal cannula.

He also has an intracranial pressure, or ICP, monitor in place that shows an ICP of 21 mmHg; and his cardiac monitor shows normal sinus rhythm.

Nurse Kenji then performs a focused neurological assessment and calculates a Glasgow Coma Scale, or GCS, score of 11, with both pupils equal and reactive to light.

Next, Nurse Kenji analyzes these cues. He reviews the electronic health record, or EHR, and notes that Felix had a computed tomography, or CT, scan that ruled out a skull fracture and intracranial bleeding but showed cerebral edema.

Nurse Kenji knows the rigid skull contains fixed amounts of brain matter; cerebral spinal fluid, or CSF; and blood, and any increase in volume of one of these components must be compensated by a decrease in one of the other components. For example, an increase in brain matter due to cerebral edema can be compensated by an adjustment to the volume of cerebral blood flow, increasing absorption of CSF, or shifting CSF from the intracranial space into the spinal column. However, in situations where these compensatory mechanisms fail, ICP can increase significantly.

If left untreated, Nurse Kenji knows that a sustained increase in ICP above 20 mmHg, called intracranial hypertension, can compromise cerebral perfusion pressure, or CPP, leading to impaired delivery of oxygen, glucose, and other nutrients to the brain. Complications of intracranial hypertension include infarction and brain herniation.

Nurse Kenji realizes that Felix needs prompt treatment to lower his ICP.