What should the nurse do immediately after inserting an intracranial pressure (ICP) monitor in a traumatic brain injury patient (motorcycle crash) with an admission Glasgow Coma Scale of 11 (E2, M3, V6)?

Immediate Post-ICP Monitor Insertion Nursing Action

The nurse should immediately assess the patient's neurologic status and compare it to the pre-insertion baseline assessment. This is the priority action to detect any acute complications from the procedure, such as hemorrhage or herniation, which could rapidly deteriorate the patient's condition 1.

Rationale for Neurologic Assessment Priority

The immediate post-insertion period carries specific risks that require prompt detection:

• Hemorrhage risk from ICP monitor placement ranges from 2-4% for ventricular catheters and 0-1% for intraparenchymal devices, making immediate neurologic assessment critical to detect acute deterioration 1
• Baseline comparison is essential because any change in neurologic status (pupillary response, motor function, level of consciousness) may indicate a procedural complication requiring urgent intervention 2
• In this patient with GCS 11 (E2, M3, V6), any decline in motor response or development of pupillary changes would be particularly concerning for intracranial hemorrhage or increased ICP 3

Why Other Options Are Incorrect

Irrigation with antibiotic solution is not standard practice and could introduce infection risk or disrupt the sterile field 1

Transducer leveling to the phlebostatic axis is incorrect because:

• ICP transducers must be leveled at the foramen of Monro (external auditory meatus or tragus), not the phlebostatic axis which is used for central venous pressure monitoring 4
• While proper leveling is important for accurate readings, it should occur after confirming the patient is neurologically stable post-procedure 4

Positioning the patient flat is contraindicated because:

• Head elevation to 20-30 degrees is the recommended position for severe TBI patients as it enhances venous drainage and reduces ICP 3
• Flat positioning would worsen cerebral venous drainage and potentially increase ICP 4
• Head elevation reduces ICP by approximately 3.9 mm Hg per 10 cm of elevation without compromising cerebral perfusion pressure 4

Subsequent Priority Actions

After completing the neurologic assessment:

1. Ensure proper head positioning at 20-30 degrees elevation to optimize venous drainage 3
2. Verify transducer leveling at the foramen of Monro for accurate ICP readings 4
3. Establish ICP monitoring parameters with goals of maintaining ICP <20-25 mm Hg and cerebral perfusion pressure 60-70 mm Hg 2, 1
4. Monitor for delayed complications as intracranial hypertension can develop over the first 3-5 days post-injury, with 25% of patients showing peak ICP elevation after day 5 5

Critical Monitoring Considerations

Given this patient's GCS of 11 with abnormal motor response (M3), they are at significant risk for developing intracranial hypertension:

• ICP of 20-40 mm Hg carries a 3.95 times higher risk of mortality and poor neurological outcome 3
• More than 50% of patients with abnormal CT scans will develop intracranial hypertension 2
• Continuous neurologic surveillance is essential as deterioration may indicate need for escalation of therapy including osmotic agents or surgical decompression 2, 3