A nurse is monitoring the intracranial pressure (ICP) of a patient with a traumatic brain injury (TBI) from an MVA. Which of the following would the nurse associate with increased ICP?

Altered respiration
Change in level of consciousness
Decorticate or decerebrate posturing
Increased blood pressure

Explanation

• A change in the level of consciousness is typically the first sign of increased ICP.

• Increased ICP puts pressure on the brainstem. This affects the patient's motor function and is indicated by posturing, either decorticate or decerebrate. Decorticate posturing is a stiff body, bent arms, clenched fists, and legs straight.  Decerebrate posturing is a stiff body, arms and legs straight with toes pointing down, and head and neck arched backwards.

• Increased BP, decreasing pulse, and altered respirations are called Cushing's Triad. These are typically late signs that represent a loss of compensatory mechanisms and indicate a presentation of brainstem dysfunction.

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