A nurse is caring for a child who has a head injury following a motor vehicle crash.
Which of the following should the nurse manifestation of increased intracranial pressure? Increased irritability Decorticate posturing Cheyne-Stokes respirations
The correct answer and explanation is :
The correct answer is Increased irritability.
Explanation:
Increased intracranial pressure (ICP) is a critical and potentially life-threatening condition that can arise from various causes, including head injuries like the one described in the question. ICP occurs when there is a rise in pressure within the skull, which can affect brain function and lead to serious complications. When the nurse is caring for a child who has sustained a head injury, it’s essential to monitor for signs and symptoms of increased ICP, as early detection and intervention can prevent severe neurological damage.
Signs and Symptoms of Increased ICP:
- Increased irritability: This is one of the earliest and most common signs of increased ICP, particularly in children. As the pressure inside the skull rises, the brain becomes less able to function properly, which can cause changes in behavior and mood. The child may become increasingly irritable or difficult to console. This irritability is often a response to discomfort and pain from the injury or the effects of the pressure on the brain. It is crucial for the nurse to report such behavior changes promptly as they may indicate worsening of the ICP.
- Decorticate posturing: Decorticate posturing is a sign of severe neurological dysfunction that can indicate worsening ICP, especially when the pressure starts to affect the brainstem. This posture involves flexion of the arms, wrists, and fingers (toward the body) and extension of the legs. It is a more advanced sign of increased ICP and usually appears when the brain’s ability to control voluntary movements is compromised.
- Cheyne-Stokes respirations: This pattern of abnormal breathing includes periods of apnea followed by deep, rapid breaths and then shallow breaths, with periods of apnea again. It occurs when there is dysfunction in the brainstem, typically as a result of very high ICP. Although Cheyne-Stokes respirations are a serious sign, they tend to manifest later in the progression of increased ICP, often when brainstem involvement is already present.
Clinical Implications:
Recognizing signs of increased ICP early is crucial for the nurse to take appropriate action, including notifying the healthcare team for further assessment and possible interventions (e.g., managing ventilation, administering medications to reduce pressure, or preparing for surgery if necessary). Increased irritability is a key early sign that should prompt further evaluation and close monitoring to ensure the child’s safety and optimal care.