Question

A client is in the intensive care unit following a motor vehicle accident with a sustained head injury. Intracranial pressure monitor (ICP) is in place with a reading of 32 . Arterial line shows a mean arterial pressure (MAP) of 80 . Which nursing action is appropriate? A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48 B. Document these results on the client record in the nurse's notes C. Turn the client on her side with her knees bent upward in preparation for a lumbar puncture D. Notify the doctor that the client has a CPP of 112

Short answer

Answer: A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48.

Step-by-step solution

Calculate CPP using the provided formula

To calculate the CPP, we can use the formula CPP=MAP-ICP. We plug in the given values of ICP (32) and MAP (80) to obtain the CPP. CPP = 80 - 32 CPP = 48 The calculated CPP is 48.

Determine the appropriate nursing action based on the calculated CPP

With the CPP calculated as 48, we can now determine the appropriate nursing action among the provided options: A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48 B. Document these results on the client record in the nurse's notes C. Turn the client on her side with her knees bent upward in preparation for a lumbar puncture D. Notify the doctor that the client has a CPP of 112 Option A is the correct answer, as it correctly identifies the calculated CPP and requests to notify the physician about the client's condition. The other options either inaccurately identify the CPP or involve actions that may not be necessary or appropriate based on the calculated CPP value.

Key concepts

Cerebral Perfusion Pressure

Cerebral Perfusion Pressure (CPP) is a critical measurement in assessing brain health, particularly after a traumatic injury. It represents the pressure gradient driving blood flow to the brain. In easier terms, it's like the pressure that pushes blood into the brain to provide it with oxygen and nutrients.
This pressure is vital for maintaining adequate brain function.

• The formula to calculate CPP is:\[ CPP = MAP - ICP \]where MAP denotes Mean Arterial Pressure and ICP is Intracranial Pressure.
• A healthy brain tissue demands a CPP between 60 to 70 mmHg.
• Values below this range suggest that the brain is not receiving enough blood, which can lead to damage.

In critical situations, like after a head injury, monitoring CPP helps healthcare professionals gauge how well the brain is being perfused and decide on therapy strategies.

Intracranial Pressure

Intracranial Pressure (ICP) refers to the pressure exerted by fluids like blood and cerebrospinal fluid inside the skull. This pressure is crucial because an increase in ICP can push the brain against the skull, causing damage.
Usually, ICP values are maintained between normal ranges (5 to 15 mmHg).

• High ICP means the brain might not get enough blood, as it can restrict blood flow, posing a risk for brain injury.
• Symptoms of raised ICP include headaches, vomiting, and decreased level of consciousness.

In cases of head trauma, measuring ICP helps healthcare providers determine the risk of herniation or brain damage, guiding appropriate interventions.

Mean Arterial Pressure

Mean Arterial Pressure (MAP) is an average blood pressure in an individual's arteries during one cardiac cycle. It's a crucial parameter, especially in critical care, as it indicates the flow and pressure of blood that supplies essential nutrients to organs, including the brain.
MAP is calculated using the formula:\[ MAP = \frac{1}{3} (SBP - DBP) + DBP \]where SBP represents Systolic Blood Pressure and DBP is Diastolic Blood Pressure.

• An adequate MAP is crucial for cerebral perfusion, and typical MAP values range from 70 to 100 mmHg.
• If MAP drops, organs may not receive enough blood, potentially compromising their function.

Understanding MAP in conjunction with CPP and ICP helps critical care nurses make informed decisions regarding patient care.

Critical Care Nursing

Critical care nursing involves providing intensive monitoring and treatment to patients with serious health conditions. Nurses in this field work in environments like ICU and require specialized skills.
The nursing interventions are vital to patient outcomes, with a strong focus on monitoring vital signs, assessing CPP, ICP, and MAP.

• Critical care nurses need to quickly interpret readings and adjust care plans to ensure patients maintain stable conditions.
• They're responsible for communicating critical changes with the medical team to prevent further deterioration of the patient's condition.
• Additionally, they provide psychological and emotional support to both patients and families during challenging times.

In summary, critical care nursing is an essential component in managing complex health environments, requiring both technical skills and compassionate care.