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
• 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.