Question

Cushing's triad is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression.

The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull (eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury.

(Option 1) Atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia.

(Option 2) Nifedipine (Procardia) is a calcium channel blocker that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the hypertension rather than just treating that sign. Ruling out a cerebral cause of the hypertension is most important.

(Option 4) The nurse would continue to perform neurologic assessments (including GCS). However, it is more important to obtain appropriate diagnostic tests and initiate treatment for the changing neurologic symptoms than to just monitor and document. In addition, the nurse should be performing these assessments more frequently than hourly in this rapidly changing client.

Educational objective:
Cushing's triad/reflex indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).

Answer 1

In the context of increased intracranial pressure (ICP) and suspected brain stem compression, the presentation of Cushing's triad, including bradycardia, rising systolic blood pressure, and irregular respirations, indicates a critical situation requiring immediate attention and diagnostic evaluation. Options 1, 2, and 4 are not the primary interventions in this scenario; rather, obtaining appropriate diagnostic tests and initiating treatment for changing neurologic symptoms take precedence.

Step-by-step explanation:

Cushing's triad, characterized by bradycardia, increased systolic blood pressure, and irregular respirations, is a late sign of increased intracranial pressure and suggests brain stem compression. In the presented case, this triad underscores the urgency of the situation, requiring swift diagnostic measures and interventions to address the potential cerebral cause of these symptoms. The focus is on ruling out hidden head trauma causing intracranial bleeding.

Option 1 (Atropine) is not indicated as there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation. Option 2 (Nifedipine) is inappropriate as treating hypertension alone does not address the underlying cause, emphasizing the need to rule out a cerebral etiology for the elevated blood pressure. Option 4 (Continuing neurologic assessments) is insufficient; frequent assessments are needed, but the priority lies in obtaining appropriate diagnostic tests and initiating timely treatment for the evolving neurologic symptoms.

In summary, recognizing the urgency of Cushing's triad in the context of increased ICP mandates a rapid and comprehensive approach to diagnostic testing and intervention. Addressing the underlying cause, particularly ruling out cerebral causes for hypertension, takes precedence over isolated treatments for individual symptoms.