NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Click or tap here to enter text.
Course Click or tap here to enter text.
:
Client Information (SBAR) Concept of the Map
D is a 21-year-old male who was admitted to the trauma ICU Intracranial Regulation
following a motor vehicle accident in which he drove his car into – Traumatic Brain
a ditch. He sustained multiple fractures, including a skull fracture, Injury (TBI) with
Situation and was diagnosed with a traumatic brain injury secondary to a Subdural
right-sided subdural hematoma and subdural hemorrhage. The Hematoma/Hemorrhag
patient is currently post–craniotomy for hematoma evacuation e
and remains sedated and intubated on mechanical ventilation.
Upon arrival at the scene, the patient was found unresponsive and
was intubated for airway protection. A CT scan revealed a right
subdural hematoma with midline shift, prompting emergent
neurosurgical intervention. He has an ICP monitor in place.
Background
Family has been informed of his condition and is present at the
bedside.
Past medical history and allergies are unknown at this time.
No prior significant neurological history is reported.
GCS: 9 (E2, V2, M5)
Pupils: Unequal – Right 5 mm sluggish; Left 3 mm reactive
ICP: 22 mmHg (elevated)
Vital Signs: BP 154/90 mmHg, HR 54 bpm (bradycardia),
RR 10/min, SpO₂ 92% on 4 L NC
Drain Output: 50 mL serosanguinous
Findings: Cushing’s triad present (↑BP, ↓HR, irregular
respirations) indicating increased intracranial pressure.
Assessment Post-op Site: Craniotomy incision intact with no signs of
active bleeding.
Risks: High risk for seizure activity and cerebral edema.
Interpretation: The patient’s findings are consistent with impaired
intracranial regulation and decreased cerebral perfusion pressure
secondary to increased ICP following TBI and hematoma
evacuation.
Continue hourly neurological assessments and ICP monitoring.
Notify the neurosurgeon immediately for ICP >25 mmHg or any
Recommendation acute neurological change.
Maintain head of bed at 30° and ensure proper head alignment to
facilitate venous drainage.
, Administer osmotic diuretics (e.g., mannitol or hypertonic saline)
as ordered to reduce cerebral edema.
Maintain normothermia and oxygenation (SpO₂ >94%) to
prevent secondary brain injury.
Implement seizure precautions and minimize environmental
stimuli.
Provide emotional support and frequent updates to the family.
Recognize Cues Analyze Cues
1. Elevated Intracranial Pressure (ICP 22
Subjective Cues (from available information patient mmHg)
is sedated and intubated; no direct verbal report
available.) Condition Identified: Increased
Intracranial Pressure (IICP) secondary to
Family reports that the patient was unresponsive traumatic brain injury and post-surgical
at the scene and has not regained consciousness cerebral edema.
since the accident. Explanation: After a TBI and craniotomy,
EMS notes indicate no purposeful movements swelling, bleeding, or impaired
before arrival, consistent with decreased level of cerebrospinal fluid (CSF) drainage can
consciousness. elevate intracranial pressure. Sustained
ICP >20 mmHg compromises cerebral
Objective Cues (clinical findings) blood flow and oxygen delivery,
potentially causing brain tissue ischemia
1. Elevated Intracranial Pressure (ICP 22 mmHg) and herniation (Wijdicks, 2022).
Link to Cue: ICP 22 mmHg confirms that
Significance: Normal ICP ranges from 5–15 intracranial compliance is impaired and
mmHg (Wijdicks, 2022). The patient’s ICP of 22 requires continuous monitoring and
mmHg indicates intracranial hypertension, management.
increasing the risk of brain tissue compression,
herniation, and decreased cerebral perfusion. 2. Cushing’s Triad (↑BP, ↓HR, irregular
Elevated ICP directly reflects impaired respirations)
intracranial regulation.
Condition Identified: Brainstem
2. Cushing’s Triad (↑BP 154/90, ↓HR 54 bpm, compression and decreased cerebral
irregular respirations) perfusion pressure (CPP) due to rising
ICP.
Significance: This classic triad is a late and Explanation: The brainstem regulates
cardiovascular and respiratory centers. As
critical sign of increased ICP, signaling
ICP rises, perfusion to these centers
brainstem compression and possible herniation decreases, triggering a compensatory
(Mauldin, 2025). It represents the body’s attempt response—hypertension (to maintain
to maintain cerebral perfusion by increasing CPP), bradycardia, and irregular
blood pressure as heart rate and respiratory drive respirations. This is a late and life-
decline. threatening sign of neurological
deterioration (Mauldin, 2025).
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Click or tap here to enter text.
Course Click or tap here to enter text.
:
Client Information (SBAR) Concept of the Map
D is a 21-year-old male who was admitted to the trauma ICU Intracranial Regulation
following a motor vehicle accident in which he drove his car into – Traumatic Brain
a ditch. He sustained multiple fractures, including a skull fracture, Injury (TBI) with
Situation and was diagnosed with a traumatic brain injury secondary to a Subdural
right-sided subdural hematoma and subdural hemorrhage. The Hematoma/Hemorrhag
patient is currently post–craniotomy for hematoma evacuation e
and remains sedated and intubated on mechanical ventilation.
Upon arrival at the scene, the patient was found unresponsive and
was intubated for airway protection. A CT scan revealed a right
subdural hematoma with midline shift, prompting emergent
neurosurgical intervention. He has an ICP monitor in place.
Background
Family has been informed of his condition and is present at the
bedside.
Past medical history and allergies are unknown at this time.
No prior significant neurological history is reported.
GCS: 9 (E2, V2, M5)
Pupils: Unequal – Right 5 mm sluggish; Left 3 mm reactive
ICP: 22 mmHg (elevated)
Vital Signs: BP 154/90 mmHg, HR 54 bpm (bradycardia),
RR 10/min, SpO₂ 92% on 4 L NC
Drain Output: 50 mL serosanguinous
Findings: Cushing’s triad present (↑BP, ↓HR, irregular
respirations) indicating increased intracranial pressure.
Assessment Post-op Site: Craniotomy incision intact with no signs of
active bleeding.
Risks: High risk for seizure activity and cerebral edema.
Interpretation: The patient’s findings are consistent with impaired
intracranial regulation and decreased cerebral perfusion pressure
secondary to increased ICP following TBI and hematoma
evacuation.
Continue hourly neurological assessments and ICP monitoring.
Notify the neurosurgeon immediately for ICP >25 mmHg or any
Recommendation acute neurological change.
Maintain head of bed at 30° and ensure proper head alignment to
facilitate venous drainage.
, Administer osmotic diuretics (e.g., mannitol or hypertonic saline)
as ordered to reduce cerebral edema.
Maintain normothermia and oxygenation (SpO₂ >94%) to
prevent secondary brain injury.
Implement seizure precautions and minimize environmental
stimuli.
Provide emotional support and frequent updates to the family.
Recognize Cues Analyze Cues
1. Elevated Intracranial Pressure (ICP 22
Subjective Cues (from available information patient mmHg)
is sedated and intubated; no direct verbal report
available.) Condition Identified: Increased
Intracranial Pressure (IICP) secondary to
Family reports that the patient was unresponsive traumatic brain injury and post-surgical
at the scene and has not regained consciousness cerebral edema.
since the accident. Explanation: After a TBI and craniotomy,
EMS notes indicate no purposeful movements swelling, bleeding, or impaired
before arrival, consistent with decreased level of cerebrospinal fluid (CSF) drainage can
consciousness. elevate intracranial pressure. Sustained
ICP >20 mmHg compromises cerebral
Objective Cues (clinical findings) blood flow and oxygen delivery,
potentially causing brain tissue ischemia
1. Elevated Intracranial Pressure (ICP 22 mmHg) and herniation (Wijdicks, 2022).
Link to Cue: ICP 22 mmHg confirms that
Significance: Normal ICP ranges from 5–15 intracranial compliance is impaired and
mmHg (Wijdicks, 2022). The patient’s ICP of 22 requires continuous monitoring and
mmHg indicates intracranial hypertension, management.
increasing the risk of brain tissue compression,
herniation, and decreased cerebral perfusion. 2. Cushing’s Triad (↑BP, ↓HR, irregular
Elevated ICP directly reflects impaired respirations)
intracranial regulation.
Condition Identified: Brainstem
2. Cushing’s Triad (↑BP 154/90, ↓HR 54 bpm, compression and decreased cerebral
irregular respirations) perfusion pressure (CPP) due to rising
ICP.
Significance: This classic triad is a late and Explanation: The brainstem regulates
cardiovascular and respiratory centers. As
critical sign of increased ICP, signaling
ICP rises, perfusion to these centers
brainstem compression and possible herniation decreases, triggering a compensatory
(Mauldin, 2025). It represents the body’s attempt response—hypertension (to maintain
to maintain cerebral perfusion by increasing CPP), bradycardia, and irregular
blood pressure as heart rate and respiratory drive respirations. This is a late and life-
decline. threatening sign of neurological
deterioration (Mauldin, 2025).
