Question

A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represent Cushing's triad? Select all that apply.

-Bradycardia

-Weak pulse

-Irregular respirations

-Increasing systolic blood pressure

-Decreasing systolic blood pressure

Answer 1

In a patient with a head injury and increasing intracranial pressure, signs of Cushing's triad include bradycardia, irregular respirations, and increasing systolic blood pressure. These symptoms should be reported to a healthcare provider immediately as they signify a potentially dangerous state requiring prompt attention.

Step-by-step explanation:

The Cushing's triad is a set of three primary signs that often indicate an increase in intracranial pressure. The clinical manifestations of the triad that a nurse should report to the healthcare provider include: bradycardia (slow heart rate), irregular respirations, and increasing systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic blood pressure). These symptoms reflect the body’s autoregulatory response to maintain cerebral perfusion in the face of increasing intracranial pressure.

A weak pulse and decreasing systolic blood pressure are not typically associated with Cushing's triad. Instead, they could be indicative of other medical conditions or complications. Therefore, when a nurse observes signs of bradycardia, irregular respirations, and increasing systolic blood pressure, it is crucial to report these findings immediately as they are suggestive of elevated intracranial pressure that may require urgent medical intervention.