Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
a. Intracranial pressure of 15 mm Hg
b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia at 128 beats/minute
ANS: C
The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
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