When assessing a patient with a head injury, the nurse recognizes that which sign is the earliest indication of increased intracranial pressure?

A. Hypertension and narrowing pulse pressure: Increased intracranial pressure leads to a widening pulse pressure rather than a narrowing one. As ICP rises, systolic pressure increases while diastolic pressure may remain stable or decrease, producing a widened pulse pressure. Narrow pulse pressure is not characteristic of late ICP elevation.

B. Elevated systolic blood pressure and bradycardia: These are classic components of Cushing’s triad, a late and ominous sign of significantly increased ICP. Rising ICP decreases cerebral perfusion, triggering sympathetic-mediated hypertension to maintain blood flow. The resulting baroreceptor response causes reflex bradycardia, indicating brainstem involvement and impending herniation.

C. Hypotension and tachycardia: Hypotension and tachycardia are more consistent with hypovolemia or shock rather than increased ICP. In elevated ICP, the body attempts to preserve cerebral perfusion by increasing systemic blood pressure, not lowering it.

D. Hypotension and bradycardia: This combination does not reflect the compensatory physiologic response to increased ICP. Late ICP elevation is associated with systemic hypertension, not hypotension, as the body attempts to overcome reduced cerebral perfusion pressure.

A. Determine a Glasgow Coma Scale score: Assessing the patient’s level of consciousness using the Glasgow Coma Scale (GCS) is the most urgent step when increased ICP is suspected. Changes in mental status are often the earliest and most sensitive indicator of rising ICP, and a rapid, structured assessment allows the nurse to identify neurologic deterioration promptly.

B. Obtain heart rate and blood pressure: Vital signs provide important information about hemodynamic status and may indicate Cushing’s triad in late-stage ICP elevation, but changes in consciousness usually precede these vital sign alterations. Immediate neurologic assessment takes priority.

C. Assess reflexes and push pulls of feet: Reflex testing and motor strength evaluation are components of a comprehensive neurologic assessment, but they are secondary to establishing the patient’s overall level of consciousness and GCS score. Delaying initial assessment could postpone recognition of acute deterioration.

D. Assess for nuchal rigidity: Nuchal rigidity is a sign of meningeal irritation, not a primary indicator of increased ICP following a craniotomy. While important to note, it is not the first assessment action when acute neurologic changes and signs of herniation are present.