A 7-year-old patient is exhibiting signs of increased intracranial pressure, including a decreased level of consciousness, anisocoria, and changes in vital signs consistent with Cushing's triad. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Initiating hypertonic saline administration to reduce cerebral edema.

A) Administering a sedative to ensure the patient remains calm.

B) Initiating hypertonic saline administration to reduce cerebral edema.

C) Positioning the patient in a Trendelenburg position to improve cerebral perfusion.

D) Providing supplemental oxygen via nasal cannula to maintain oxygen saturation.

A 7-year-old patient with increased intracranial pressure is now showing signs of a decreased level of consciousness and anisocoria. Which of the following nursing interventions is the priority to help stabilize her condition?

A) Elevate the head of the bed to 30 degrees.

B) Administer a sedative to decrease irritability.

C) Provide supplemental oxygen to maintain saturation above 95%.

D) Initiate seizure precautions immediately.

A patient with increased intracranial pressure (ICP) has been administered hypertonic saline. Which priority nursing assessment should be performed to monitor the effectiveness of this intervention?

B) Assess the patient's level of consciousness and pupillary response.

A) Measure the patient's urine output for signs of diuresis.

B) Assess the patient's level of consciousness and pupillary response.

C) Monitor the patient's blood glucose levels for hyperglycemia.

D) Check the patient's peripheral capillary refill time for circulation status.

A patient with increased intracranial pressure is being treated with hypertonic saline. Which change in the patient's condition would most likely indicate an improvement in cerebral perfusion?

C) Increase in Glasgow Coma Scale score from 8 to 10

A) Decrease in heart rate from 88 bpm to 70 bpm

B) Increase in blood pressure from 115/75 mmHg to 130/85 mmHg

C) Increase in Glasgow Coma Scale score from 8 to 10

D) Increase in serum sodium level from 145 mmol/L to 150 mmol/L

A patient with a new subdural hematoma is displaying signs of increased intracranial pressure (ICP). Which intervention should the nurse prioritize to help manage the patient's condition and why?

B) Elevate the head of the bed to 30 degrees to facilitate venous drainage

A) Administer hypertonic saline to reduce cerebral edema

B) Elevate the head of the bed to 30 degrees to facilitate venous drainage

C) Provide analgesics to reduce pain and stress

D) Initiate deep suctioning to clear airway secretions

A nurse is caring for a patient who has developed increased intracranial pressure and a new subdural hematoma following the administration of hypertonic saline. Which of the following interventions should the nurse prioritize to help manage the patient's intracranial pressure and prevent further neurological deterioration?

A) Administering prescribed osmotic diuretics

B) Encouraging frequent repositioning to prevent pressure injuries

C) Providing continuous verbal stimulation to assess cognitive function

D) Initiating enteral feeding to maintain nutritional status

A pediatric patient has undergone surgical evacuation of a subdural hematoma and is now in the postoperative period. The patient's Glasgow Coma Scale score has improved, but anisocoria persists. What is the most appropriate nursing intervention to address the ongoing risk of increased intracranial pressure?

A) Administer prescribed osmotic diuretics to reduce cerebral edema.

B) Encourage early ambulation to promote circulation and prevent deep vein thrombosis.

C) Perform deep suctioning regularly to maintain airway patency.

D) Increase intravenous fluid rate to ensure adequate cerebral perfusion.

A pediatric patient is in the immediate postoperative period following the evacuation of a subdural hematoma. The nurse notes that the patient's Glasgow Coma Scale score has improved from 8 to 10, but anisocoria persists. What is the nurse's best action to address the patient's current neurological status?

A) Continue to monitor the patient's neurological status and document findings every hour.

B) Administer a dose of mannitol to reduce intracranial pressure as per the PRN order.

C) Increase the head of the bed to 45 degrees to facilitate venous drainage and decrease ICP.

D) Notify the neurosurgeon immediately about the persistent anisocoria.

A pediatric patient is in the pediatric intensive care unit following a surgical intervention and presents with new-onset lethargy and a decreased Glasgow Coma Scale score. A CT scan reveals a small subdural fluid collection without significant mass effect. Which nursing intervention is most appropriate to prioritize at this time?

A) Increase the frequency of neurological assessments to every 15 minutes.

B) Administer additional analgesics to ensure the patient remains comfortable.

D) Encourage the family to interact with the patient to promote cognitive stimulation.

A pediatric patient is 3 days postoperative from a neurosurgical procedure and presents with increased lethargy and a Glasgow Coma Scale score of 9. A repeat CT scan shows a small subdural fluid collection. What is the priority nursing intervention at this time?

B) Elevate the head of the bed to 30 degrees to assist with intracranial pressure control.

A) Increase fluid intake to prevent dehydration.

B) Elevate the head of the bed to 30 degrees to assist with intracranial pressure control.

C) Administer a sedative to ensure the patient remains calm and resting.

D) Initiate active range of motion exercises to prevent muscle atrophy.

Pediatric Head Injury - Nursing Case Study

Pathophysiology

• Primary mechanism: Traumatic Brain Injury (TBI) occurs when an external force causes the brain to collide with the skull, leading to neuronal damage and potential hemorrhage. This can result in focal or diffuse injury, with symptoms ranging from mild concussions to severe brain damage depending on the force and location of impact.

• Secondary mechanism: Edema and increased intracranial pressure (ICP) often follow the initial injury, as the brain's inflammatory response leads to swelling. This can compromise cerebral perfusion and oxygen delivery, exacerbating neuronal injury and potentially leading to brain herniation if not controlled.

• Key complication: Hypoxia and ischemia can occur due to disrupted blood flow and elevated ICP, further impairing brain function and increasing the risk of long-term neurological deficits. Prompt management is crucial to prevent irreversible damage and improve outcomes.

Patient Profile

Demographics:

7-year-old female, elementary school student

History:

• Key past medical history: Asthma, no previous head injuries

• Current medications: Albuterol inhaler as needed for asthma

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Headache and confusion following a fall

• Key symptoms: Nausea, intermittent vomiting, drowsiness, irritability, and difficulty concentrating

• Vital signs: Temperature 99.4°F, Heart Rate 110 bpm, Respiratory Rate 24 breaths/min, Blood Pressure 105/70 mmHg, Oxygen Saturation 96% on room air

Section 1

Change in Patient Status:

A few hours after the initial evaluation, the 7-year-old patient exhibits a noticeable change in her neurological status, raising concerns about potentially worsening intracranial pressure. Her drowsiness has progressed to a decreased level of consciousness, and she is now responding only to painful stimuli. Her verbal responses are incoherent, and she exhibits increased irritability when stimulated, which could be indicative of further cerebral irritation or swelling. The physical exam reveals a slight anisocoria, with her right pupil larger and less reactive to light compared to the left, suggesting possible unilateral brain swelling or a developing hematoma.

Vital signs now show a significant change: her heart rate has decreased to 85 bpm, and her blood pressure has increased to 120/80 mmHg, a sign of Cushing's triad, indicating rising intracranial pressure. Her respiratory rate remains elevated at 26 breaths/min, and her oxygen saturation has dropped slightly to 94% on room air. These clinical findings prompt an immediate call for a repeat CT scan to assess for any new bleeding or worsening edema.

The new diagnostic imaging reveals a subtle midline shift and increased cerebral edema compared to the initial scan, suggesting increased pressure and risk of herniation. This deterioration in her condition necessitates an urgent consultation with neurosurgery and consideration of interventions such as osmotic diuretics or hypertonic saline to reduce intracranial pressure. The healthcare team must act swiftly to stabilize her condition and prevent further complications, emphasizing the need for continuous monitoring and reassessment of her neurological status and vital signs.

Section 2

Response to Interventions:

Following the urgent neurosurgical consultation, the decision is made to administer hypertonic saline to reduce the intracranial pressure and mitigate the risk of brain herniation. Within an hour of administration, the patient's neurological status shows subtle signs of improvement. Her level of consciousness slightly improves, as she begins to respond more purposefully to painful stimuli, though she remains disoriented and confused. The anisocoria persists, but there is a slight improvement in the pupillary reaction to light on the right side. Vital signs reflect a marginally positive response to the treatment: her heart rate remains stable at 88 bpm, and her blood pressure has decreased to 115/75 mmHg, suggesting a decrease in intracranial pressure. Oxygen saturation improves to 96% on supplemental oxygen via nasal cannula.

While these initial responses to treatment are promising, the healthcare team remains vigilant, aware that the risk of further complications persists. They conduct frequent neurological checks and continue to monitor vital signs, paying close attention to any signs of increased intracranial pressure or neurological decline. The patient is closely observed for potential side effects of the hypertonic saline, such as electrolyte imbalances. Lab tests indicate her serum sodium has increased to 145 mmol/L, necessitating careful monitoring to prevent hypernatremia.

The team collaborates to ensure a comprehensive care plan is in place, including further imaging studies to track changes in cerebral edema and midline shift. The nursing staff is prepared to educate the family about the potential for fluctuating neurological status and the importance of continuous monitoring. They emphasize the need for ongoing evaluation to address any new complications that may arise, ultimately aiming to stabilize the patient's condition and prevent long-term neurological deficits.

Section 3

As the healthcare team continues to monitor the patient closely, a new complication emerges. Approximately six hours after the administration of hypertonic saline, the patient exhibits increased irritability and restlessness, which are concerning signs of possible worsening intracranial pressure. Her heart rate rises to 110 bpm, and her blood pressure increases to 130/85 mmHg. Although her oxygen saturation remains stable at 96%, the increased blood pressure and heart rate suggest the potential onset of Cushing's triad, a clinical sign of increased intracranial pressure. Repeat neurological examination reveals that the anisocoria is now more pronounced, with a sluggish response to light on the right side, and her Glasgow Coma Scale score decreases to 8, indicating a decline in her level of consciousness.

Given these changes, the team promptly decides to repeat imaging studies, including a CT scan of the head, to assess for any progression of cerebral edema or new bleeding. The results show an increase in midline shift compared to the previous scan, and there is now evidence of a small, new subdural hematoma. These findings correlate with the patient's deteriorating neurological status and confirm the need for further intervention.

In response to these developments, the neurosurgery team considers the possibility of surgical intervention to evacuate the hematoma and relieve pressure on the brain. Meanwhile, the nursing staff initiates additional measures to manage the patient's intracranial pressure, including elevating the head of the bed to 30 degrees and ensuring a quiet environment to minimize stimulation. The family is updated on the situation, with a focus on the necessity of potential surgery and the critical nature of the ongoing treatment. This situation requires the healthcare team to employ clinical reasoning skills to balance the risks and benefits of surgical versus continued medical management, while maintaining vigilant monitoring of the patient's status.

Section 4

As the healthcare team continues to manage the patient, the neurosurgery team decides to proceed with surgical intervention to evacuate the subdural hematoma, given the increasing midline shift and the patient's deteriorating neurological status. Before surgery, the patient is prepared in the preoperative area, where the nursing staff conducts a thorough reassessment to ensure stability for the upcoming procedure. The patient's vital signs reveal a heart rate of 115 bpm and blood pressure of 135/90 mmHg, indicating persistent hypertension and tachycardia. Her Glasgow Coma Scale score remains at 8, underscoring the need for urgent intervention. The nursing team also notes that the anisocoria has not improved, with the right pupil still sluggish in response to light, highlighting the ongoing intracranial pressure issues.

Intraoperatively, the neurosurgical team successfully evacuates the hematoma, and the procedure is completed without complications. Post-surgery, the patient is transferred to the pediatric intensive care unit for close monitoring. In the immediate postoperative period, the nursing staff observes a gradual improvement in her neurological status. Her Glasgow Coma Scale score increases to 10, with the patient exhibiting spontaneous eye-opening and purposeful movement. Vital signs postoperatively show a heart rate of 100 bpm and blood pressure of 125/80 mmHg, suggesting a stabilization trend. However, the anisocoria persists, requiring continuous assessment to monitor for any signs of recurrent intracranial pressure elevation or neurological deterioration.

The healthcare team remains vigilant for potential complications such as infection, seizures, or re-bleeding, which could impact the patient's recovery trajectory. Laboratory results, including a complete blood count and electrolyte panel, are within normal limits, providing reassurance regarding the patient's immediate postoperative status. The team plans to continue supportive measures such as maintaining head elevation and a low-stimulation environment, alongside frequent neurological assessments. These measures, combined with the surgical intervention, aim to optimize the patient's recovery and prevent further complications. The family is kept informed of the patient's progress and the continued need for intensive monitoring and supportive care.

Section 5

In the days following the surgical intervention, the patient's condition remains stable, with continuous monitoring in the pediatric intensive care unit. However, on the third postoperative day, the nursing staff observes a subtle yet concerning change in the patient's status. The patient, who had been gradually improving, now appears more lethargic and difficult to arouse. Her Glasgow Coma Scale score regresses slightly to 9, reflecting a decrease in responsiveness, particularly in her verbal response. Vital signs show a slight increase in blood pressure to 130/85 mmHg and heart rate to 105 bpm, prompting the team to reassess for potential complications.

A repeat CT scan of the head is ordered to rule out any new developments, such as re-bleeding or edema. The results reveal a small amount of new subdural fluid collection, suggestive of potential re-accumulation of blood or cerebrospinal fluid leakage. While the midline shift has not worsened, the findings necessitate a multidisciplinary discussion to determine the best course of action. The neurosurgery team considers the possibility of conservative management with close observation and supportive care, given the absence of significant mass effect.

In response to these developments, the healthcare team intensifies their monitoring efforts, with a focus on neurological assessments every hour and maintenance of strict head elevation at 30 degrees to aid in intracranial pressure control. Anticipating the risk of seizures due to the recent changes, prophylactic antiepileptic medication is initiated. The care team engages in ongoing discussions with the patient's family, explaining the new findings and the rationale for the current management approach. This vigilant observation and timely intervention aim to prevent further deterioration and support the patient’s gradual recovery trajectory.