(bell ringing)
- Welcome to the Rapid Response RN Podcast,
helping you keep your finger on the pulse
of your patient's condition.
With real life stories from the front lines of nursing,
this podcast can help you sharpen your assessment skills,
improve your ability to recognize the signs
and symptoms of your patient's decline,
be inspired to speak up and advocate,
and know how to jump into action
to promote the best outcome for your patients.
- Hey everybody, I'm your host, Sara Lorenzini,
a rapid response nurse and educator
who loves telling stories to teach critical thinking.
On this episode, we're going to talk about
one of my first experiences responding to an emergency
as a nursing student.
Coincidentally, I had just gotten the neuro lecture
right before I encountered a true neuro emergency.
I also got to see how important it is
to trust your intuition and advocate for the patient,
even if your concerns are dismissed initially.
Speaking up, save this patient's life.
So let me tell you about sweet Mrs. Johnson.
That wasn't her name, obviously, HIPAA,
but that's what I will refer to her as for this episode.
I was in my third semester of med search clinicals
and we were on the neuro med search floor.
The nurse I was assigned to, we'll call her PAM,
was not the warm and fuzzy type.
In fact, the other nursing students
would specifically ask not to have her
because she was kind of rude and condescending
towards the students and a bit lazy
and didn't want to help with anything.
But I guess since I never asked not to be with PAM,
I got assigned to her once again on this clinical day.
Now, this is almost 20 years ago.
So I was barely 18 years old
and I did not have the confidence
in my nursing knowledge and assessment skills
that I have today.
But my drive to do is right,
no matter what the cost, has been there since birth.
So I guess I had that in my favor.
Our patient, Mrs. Johnson, a dear elderly lady
was a post-op craniotomy.
I couldn't tell you what surgery he had,
but I remember her cute little half-shaved head
and staple line and her pink floral old lady house coat
that she wore over top of her hospital gown.
I took her morning vitals around like 7.30
to reform my morning assessment.
All her vitals were within normal limits,
heart rate in the 80s, blood pressure 120 over 70-ish,
respiratory rate of 14.
Her neuro-assessment was unremarkable
with equal pupils and strength bilaterally.
She was alert and oriented and told me all about her grandkids
and how much they liked her cooking.
I got her to the chair to eat her breakfast
and she just picked at it and said she had a headache
and wanted to get back to bed for a nap.
She didn't want any pain medication.
Just said she felt tired and thought she needed to sleep.
So around 8.30 after her morning meds,
I put her back to bed.
I peaked in and checked on her at nine
and again at 10 and close to 11, she was still sleeping.
So I decided it was time to wake her up
and get her cleaned up and ready for lunch.
But when I tried to wake her, she just moaned.
So I went to tell Pam and she said,
"Honey, she is 80 years old
"and she just had brain surgery.
"Let her sleep for God's sakes."
I was like, "Pam, you don't want to just come look at her?
"She wasn't like this earlier."
She said, "Meal trays don't come till noon.
"Let her sleep till then and then you can wake her up."
I said, "Okay, well, I'm just gonna check
"her bottle signs just in case."
Pam said, "Whatever you wanna do, honey."
So I rechecked Mrs. Johnson's bottles
and her heart rate was 54 now
and her blood pressure was 175 over 35.
And when I tried to count her respiratory rate,
it was super irregular with long pauses and little gasps.
Definitely having some periods of apnea.
So I tried to check her pupils again
and they weren't as brisk as they were in the morning.
And even with all of that stimulation,
she really didn't wake up.
So I run and get Pam and I told her the new bottle signs
and she said, "You need to calm down, honey.
"A lot of elderly patients get a little bradycardic
"in their sleep and 54 isn't even that low."
And the doctor's blood pressure parameters
are to keep the BP less 180 systolic.
"I am not gonna call the neurosurgeon
"about a blood pressure of 175."
I said, "But what about her pulse pressure?
"It's much wider than before."
She wasn't impressed.
And then it was clear that I was getting annoying to her
but I kept going.
But the way she was breathing was very regular
and her pupils weren't as brisk as they were this morning.
She responded, "Now, honey,
"have you never seen an old person sleep?
"She probably decides undiagnosed sleep apnea.
"And think about the lighting in the room at 7 a.m.
"when you first heard her until now.
"The pupils react differently when it's broader in the room.
"You're making a big deal out of nothing."
But it didn't feel like nothing to me.
I understood all of her rationales
for why what I thought was concerning might not be.
But I just didn't feel okay with how sleepy she was.
I told Pam, "You don't wanna just come look at her
"to see if it's worth calling the neurosurgeon?"
She said, "I'm still passing my morning meds
"and I'll come see her when I get to her."
No, this was back in 2003
and rapid response teams weren't a thing at the time.
Otherwise, I probably would've just called a rapid response.
But I went to who I knew could help me.
I found my nursing professor and told her
I thought I needed to call the neurosurgeon
about my patient.
She helped me find the doctor's number
and reviewed the S-bar with me
so I felt ready to make the call.
So I called the number and the operating room nurse answered
and she said, "The neurosurgeon was in surgery
"and asked if it was an emergency."
I said, "Well, I think so."
She said, "Okay, I'm putting you on speakerphone."
I waited out of the stress of calling the neurosurgeon.
Now I'm on speakerphone for the whole operating room
to hear me.
I proceeded.
Hi, Dr. Neurosurgeon.
This is Sarah, the nursing student
taking care of Mrs. Johnson and 65-54.
She's two days post-craniatomy
and this morning she was talkative
with normal bottle signs.
And then she got a headache
and asked to lay down for a nap.
And now I can barely wake her up
and her bottles are different than this morning.
Her heart rate is 54
and her blood pressure is 175 over 35
and her breathing pattern is very irregular.
I think her pupils are a little slower
to react than they were this morning.
I'm new to care for patients after brain surgery
and so I asked the nurse
and she thought it wasn't a big deal
but she is really drowsy.
Like, I can't wake her up.
And I figured it was worth letting you know.
Is there anything that you would like me to do?
He said, "Oh, thanks for letting me know.
Has she had any medication that would make her drowsy?"
I said, "No.
All she got this morning was a colase
and her normal anti-hypertensives
but her systolic blood pressure is actually higher
than it was this morning.
And she didn't want any pain medication for her headache."
He said, "Okay.
I'm gonna order a stat CT for overhead
and I'll come see her after I've finished this case."
I said, "Okay.
I'll get her a CT stat.
Thank you."
My professor let me go with her to CAT scan
and while she was still in the scanner,
the CT tech looked at me and said,
"She has a big old bleed.
We need to get her off my CT table
and back to the operating room."
So, long story short,
we ended up taking her back to the OR
where the surgeon was able to repair the bleeder.
When I returned to CT to tell Pam
about Mrs. Johnson's rain bleed,
she was just like, "Okay, thanks."
And that's it.
But I didn't need her recognition or anyone else's.
I was honestly much more worried for Mrs. Johnson
than anything else.
And I wish that I had went back and evaluated her earlier
rather than letting her sleep for two hours.
And I played the story over and over again in my head,
trying to remember her bleeding pattern and pupils
and kicking myself for not even assessing for posturing.
I learned so much that day,
not just about increased intracranial pressure
and how it presents,
but also about the valuable role
the nurse plays in monitoring patients.
How important it is to know the patient's baselines.
You can actually detect changes
and that it's always worth the risk of embarrassing yourself
to speak up when you're concerned about a patient.
So, let's take some time to break down
what exactly happened with Mrs. Johnson
and how her signs and symptoms correlate
with increased intracranial pressure.
You may remember from nursing school,
the Monroe Kelly Doctrine,
which basically says that the skull of an adult
is a closed vault that contains the brain matter itself,
the blood flowing through the brain,
and the cerebral spinal fluid or CSF to cushion it all.
Problem is, each component is allotted a set amount
of real estate in the skull.
And since the skull is a fixed size,
if one of those components starts to increase in size,
the other two components are forced to decrease,
be compressed or herniate into the brainstem.
So, if the brain, blood volume or CSF grows in volume,
then the patient will have increased intracranial pressure.
If the intracranial pressure is too high for too long,
this can lead to brain death and ultimately loss of life.
For example, when someone has a brain injury
and the brain starts to swell,
then that means there's less room for adequate blood flow
to the brain and less space for CSF.
Or like in Mrs. Johnson's case,
she had blood leaking into the space outside
of the blood vessels, where it's supposed to be.
So that leaves less space for CSF
and for the brain to occupy.
Additionally, when blood is touching
the brain tissue directly,
it really irritates the brain tissue.
And in response, the brain starts to swell.
So now you have blood taking up more space
and brain swelling taking up more space.
So this is double bad for intracranial pressure.
If our patient were to develop increased intracranial pressure,
what would be some of the early signs that we could detect?
Well, for awake patients,
they could have projectile vomiting,
often without nausea.
They just start puking across the room.
Or headache is another early sign,
but the telltale sign of increased ICP
is altered mental status.
As the ICP increases,
the patient will become more and more drowsy
and ultimately unresponsive.
Eventually, you'll likely see pupil changes,
which will vary depending on what kind of injury you have,
but any alteration from what you know to be baseline
is worth letting someone know.
The key is knowing the baseline.
I had assessed Mrs. Johnson's pupils in the morning,
and they were equal and reacted briskly to light.
But after Mrs. Johnson developed bleeding into her brain,
they were very slow to react, almost non-reactive.
But pupil changes are one of the last things that you'll see.
So don't wait for a blown or non-reactive pupil,
so start thinking something's out.
There are a couple more things that you might see
that could indicate increased ICP.
You might have heard it called Cushing's Triad.
Cushing's Triad has nothing to do with Cushing's syndrome.
That's a totally separate thing.
But Cushing's Triad is a set of three assessment findings
that when presenting together,
should make you think increased ICP.
And Mrs. Johnson had all three.
The first is hypertension, but not just any hypertension.
Hypertension with a widened pulse pressure,
which means the systolic is getting higher
and the diastolic is dropping,
making the gap between the two wider and wider.
The second is bradycardia,
or heart rate less than 60 beats per minute.
And the third is irregular breathing.
When I rechecked Mrs. Johnson's vitals,
her systolic BP had gone up by almost 60 millimeters
of mercury, despite the morning antihypertensives
that I had administered.
And her heart rate was 30 beats slower
than what had been with her morning vitals.
And when I tried to count her restorations,
there was no pattern to her breathing
as she was having some long pauses.
That, my friends, is classic Cushing's Triad.
You also might have heard it called Cushing's Reflex
or Cushing's Response, but I like to remember it as a triad.
So I remember that the symptoms from presenting together
should make me think increased ICP every time.
Let's break down each component of the triad
in the order of which they present.
The first phase is hypertension.
As the intracranial pressure increases,
the body wants to ensure
that the brain still gets blood flow,
also known as cerebral perfusion.
So it compensates by increasing the blood pressure
to overcome the pressure inside the skull.
Initially, the heart rate will also increase.
The body's trying to increase cardiac output,
but then eventually you'll see that turned
to bradycardia as phase two kicks in.
The pathophysiology of phase two is debatable.
So either the baroreceptors in the EOSA hold up,
this BP is too high and they activate
a parasympathetic nervous system to calm things down a bit,
leading to vagal stimulation and ultimately bradycardia.
Or the compression of the brain to the spinal cords
to stimulate the vagus nerve, also leading to bradycardia.
Either way, the takeaway is bradycardia is a bad sign,
often that herniation is eminent or already occurring.
And finally, phase three is when
the funky neuro breathing starts.
The brain stem controls your breathing rate and pattern
and when it's being squished,
it kind of does a poor job of controlling respirations.
So we have talked about Mrs. Johnson's headache,
then alter mental status,
her vital signs reflecting Cushing's triad
and her pupil changes.
What we haven't talked about yet is posturing.
And I'll be honest, I didn't even think to check for it.
I was so early in my career
that I didn't even cross my mind until after the fact.
But now I look for it every time
I have an unerasable patient.
If you have no idea what I'm talking about,
please Google it for a visual,
since you can't see what my hands are doing right now,
trying to demonstrate.
So when brain injury is present,
the extremities could start to move in a predictable posture.
Dekordicate posturing,
which indicates that the injury is occurring
higher in the midbrain,
is when the extremities kind of curl inwards
towards the core.
Keyword being core, like de-cordicate.
So the arms move in towards the chest
and the feet kind of point inwards too.
The cerebrate or discerebrate,
I've heard it said both ways,
posturing is even worse as it indicates
that the injury has progressed
through to the brainstem.
And that is what you would see
with the extremities kind of pointing out.
The hands externally rotate and curl
and the feet point downward kind of like a ballerina.
Think extend.
The word discerebrate has more E's in it than de-cordicate.
So think E for extend.
The arms and legs extend.
And this is a very, very ominous sign.
So remember, you don't have to wait for posturing
or Cushing's Triad to speak up.
Start advocating for your patient
when they had the first sign of altered mentation.
Unless you work on a neuro floor,
brain bleed is not a common complication
for most patients' hospital stays.
I'd say about a third of the rapid responses I go to
are called for unresponsiveness,
but a very minuscule percentage of those
are from bleeding into the brain.
There are so many things that I tried to roll out
when the nurse tells me he was fine
and now we can't wake him up.
Things like hypoglycemia, too much opioid,
or benzodiazepines on board, hypotension,
bradycardia, electrolyte imbalance, hypoxia, hypercapnia,
acidosis, sepsis, stroke, I could keep going.
But I get a history while I'm assessing the patient
and getting them on my monitor.
And usually I can narrow the source down
to one or two likely reasons for the altered mental status.
And by the time I get the whole story from the nurse,
I have kind of a good direction for what to roll out.
My point is, you don't need to get a stat CT
every time your patient has a headache.
And you don't need to be afraid
that your patient requesting a nap
might have increased intracranial pressure.
This is a very rare thing.
But don't ever let yourself swing the other direction
and get in the spectrum and become apathetic
like Nurse Pam, who downplayed every symptom.
You know, her rationales were all correct.
Patients are sleepy after surgery.
The elderly do breathe funny sometimes when they sleep
and their heart rate can drop a little.
A blood pressure of 175 is not that high
and pupils do react slower
when ambient light in the room is brighter.
She knew all the same information that I did
about increased ICP.
But since brain bleeds rarely happen,
but sleepy, post surgical, funny, breathing elderly patients
that sometimes get braided cardiac happen all the time,
I can see why she had learned to write that off as nothing.
But here's what I had that she didn't.
I was with the patient.
I don't totally understand nursing intuition,
but I do know that I have to be present with the patient
for her to start kicking in.
For example, when I worked in the ER,
we would get EMS radio reports all the time.
And I would have all the data
about the patient's bottle signs and symptoms and history,
but it wasn't until I could see the patient with my own eyes
that I could get a feel for how sick they really were.
But she hadn't even stepped foot into the room yet.
So I would hope that if she had actually seen Mrs. Johnson,
that her nursing intuition would have kicked in
and started alarming and that would have overwritten
all of her rationales.
And she would have the same sense of urgency that I had,
but I guess we'll never know.
Takeaway is sometimes when you're informing the doctor
or respiratory therapist or whatever other member
of the interdisciplinary team that you're collaborating with
that something is wrong or you're worried
or concerned about something,
it's hard to fully convey that feeling that you're getting,
you know, that something is wrong to a person
who doesn't see what you're seeing.
If you don't feel like your point's getting across,
just ask them to come see the patient for themselves.
I've had many doctors thank me for being so pushy
after they arrived at the bedside
and realized how sick the patient truly was.
Think about it this way.
If the nurse tech called you and said they're concerned
about another one of your patients,
wouldn't you be grateful that they did?
Even if it interrupted what you were doing?
I know I would.
I would say thank you so much for letting me know.
I'll be right there to see what's wrong.
I would never be annoyed that they notified me of a change.
Even if it turned out to be no big deal,
I'd want to confirm that with my own eyes.
And I would never make them feel bad for calling me
even if it wasn't a true emergency.
We're all on the same team
and we need each other to provide
the best care to our patients.
So if the person on the other end of the phone
is giving you a hard time,
well, that's it, their issue, not yours.
It's called patient advocacy.
It's what you're called to do.
It's what you're paid to do.
And as long as you're respectful,
you should never feel bad for interrupting someone
when you're worried about your patient.
So let's take a minute to review.
Increased intracranial pressure occurs
because one or more of the contents inside the skull
is taking up more than it's allotted
amount of space in the cranium.
Some of the early signs of increased ICP
are headache, vomiting,
altered mental status, usually lethargy.
But as things progress,
you can start to see an increased blood pressure
as the body tries to overcome the intracranial pressure
to still refuse the brain.
Then bradycardia as the vagus nervous stimulated,
then an irregular breathing pattern.
We call these three symptoms
when presenting simultaneously Cushing's triad.
You may also see pupillary changes.
Either the pupils are pinpoint or huge
or different sizes called anisecoria,
or they're slow or non-reactive.
And make sure you pull back the covers
and assess for posturing.
Either the arms and legs are curled inward
in a decordicate posture
or extended outward in a cerebrate posture.
All the symptoms I just lifted
warrant a concerned call to the provider
or an activation of the rapid response team.
Don't be afraid to speak up.
Your patient can't
and they're counting on you to be their advocate.
Well, that's it for today's episode.
If you like this podcast, I'd love to hear from you.
You can shoot me an email with questions or comments
and it would mean so much
if you could take a moment to write a review on iTunes
as this helps more listeners find this podcast.
Thanks for listening
and I hope you learn something that will save a life.
Remember, nursing is a team sport.
So trust your intuition and don't give up advocating
until you are confident you've done what's right
by your patient.
You've been listening to the Rapid Response RN podcast.
The views and opinions expressed on this show
are that of Sarah Lorenzini and hers alone.
They are not intended as medical advice
and should not take the place
of your institution's policies or procedures.
Evidence-based practice is ever-changing
and your patient's care should reflect
the current best practice.
If you want to get in contact with Sarah,
you can find her at
[email protected]
or on the Rapid Response RN podcast Facebook page
as well as the podcast website rapidresponsern.com.
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