For a patient with traumatic brain injury from a motorcycle crash and an admission Glasgow Coma Scale of 11 (eye 2, motor 3, verbal 6), which action should the nurse take to prepare for intracranial pressure monitoring?

Preparing a Patient for ICP Monitoring After Traumatic Brain Injury

The nurse should reassess the patient's neurologic status before ICP monitoring is initiated, as repeated neurological examination is essential to detect secondary neurological deterioration and guide the decision for invasive monitoring.

Rationale for Neurologic Reassessment

The patient presents with a GCS of 6T (E2, M3, V-intubated), which falls into the moderate-to-severe TBI category (GCS ≤8 when accounting for intubation). Before proceeding with invasive ICP monitoring, the nurse must perform a comprehensive neurological reassessment to establish a baseline and detect any acute changes that might alter management priorities 1.

Why Neurologic Assessment Takes Priority

• Repeated neurological examination is mandated by guidelines to detect secondary neurological aggravation during initial TBI management 1
• The motor component (M3 in this case) remains the most robust indicator of TBI severity in intubated patients and correlates well with outcome 1
• A decrease of at least two points in the Glasgow Coma Score should trigger immediate CT scanning before proceeding with other interventions 1
• Pupillary size and reactivity must be assessed, as anisocoria or bilateral mydriasis are independent indications for ICP monitoring and affect prognosis 2, 3

Why the Other Options Are Incorrect

Explaining the Sterile Flush System

• This is a technical detail that can be addressed after the immediate clinical assessment
• The priority is clinical evaluation, not equipment education 3

Explaining ICP Waveforms to Family

• While patient/family education is important, it is not a preparation step for the procedure itself
• This should occur after the monitoring is established and the patient is stabilized 4

Positioning Patient Supine and Flat

• This is contraindicated in TBI patients with potential elevated ICP
• Head of bed elevation (typically 30 degrees) facilitates venous drainage and helps control ICP 1
• Flat positioning can worsen intracranial hypertension and should be avoided 5

Clinical Algorithm for ICP Monitor Preparation

Step 1: Immediate Neurologic Assessment

• Document current GCS components (Eye, Motor, Verbal/intubated status) 1
• Assess pupillary size and reactivity bilaterally - critical prognostic indicator 2, 3
• Check for focal neurological deficits 1
• Evaluate for signs of herniation (Cushing's triad, posturing) 3

Step 2: Verify Indications for ICP Monitoring

This patient with GCS 6T qualifies for ICP monitoring if:

• CT scan shows abnormalities (compression of basal cisterns, midline shift >5mm, hematoma >25mL, disappearance of ventricles) 2, 3, 6
• Even with normal CT, monitoring may be indicated given the severe GCS and inability to perform reliable neurological examination 2

Step 3: Assess for Contraindications

• Verify coagulation status - correct coagulopathy before invasive monitoring 1
• Check for hemodynamic instability requiring immediate correction 1
• Ensure no life-threatening extracranial injuries take precedence 6

Step 4: Prepare for Monitoring

• Maintain head of bed elevation (not flat positioning) 5
• Ensure adequate sedation and analgesia to prevent ICP spikes 1
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1
• Avoid hypoxemia (maintain SaO2 >90%) as it dramatically worsens outcomes 1

Critical Pitfalls to Avoid

• Never position TBI patients flat - this impairs venous drainage and can precipitate intracranial hypertension 5
• Do not proceed with ICP monitoring without current neurological assessment - acute deterioration may indicate need for emergent CT or surgical intervention instead 1
• Avoid hypotension during preparation - even brief episodes (SBP <90 mmHg for >5 minutes) significantly increase mortality 1
• Do not delay monitoring for family education - clinical priorities supersede educational activities in the acute phase 3

Expected Complications of ICP Monitoring

The nurse should be aware of monitoring risks:

• Infection rates: 10% for ventricular catheters, 2.5% for intraparenchymal devices 2
• Hemorrhage rates: 2-4% for ventricular catheters, 0-1% for intraparenchymal devices 2
• Catheter placement failure: approximately 10% 2