A nurse is developing a plan of care for a client who recently sustained a severe traumatic brain injury and is at high risk for increased intracranial pressure (ICP). Which of the following basic care and comfort interventions should the nurse include? Select all that apply.
- Maintain the head of the bed elevated at 30 degrees.Answer
- Align the client's head and neck in a neutral, midline position.Answer
- Maintain a quiet, dimly lit environment to reduce sensory stimulation.Answer
- DFlex the client's hips to 90 degrees when repositioning to prevent sliding.
- EDirect the unlicensed assistive personnel to evaluate swallowing ability during oral care.
- FApply bilateral soft wrist restraints immediately to prevent the removal of medical devices.
Answer
The correct interventions are maintaining the head of the bed at 30 degrees, aligning the head and neck in a neutral position, and providing a quiet, dimly lit environment.
For a client at risk of increased intracranial pressure (ICP), basic care and comfort measures must focus on optimizing cerebral perfusion and minimizing metabolic demand. Maintaining the head of the bed at 30 degrees and keeping the head and neck in a neutral, midline position facilitates optimal venous drainage from the brain via the jugular veins. Providing a quiet, dimly lit environment reduces sensory stimulation, which helps decrease metabolic demand and prevents spikes in ICP.
Step-by-Step Solution
Key Concept
Basic care and comfort for clients with or at risk for increased intracranial pressure must prioritize interventions that promote cerebral venous drainage (e.g., proper positioning) and reduce metabolic demand (e.g., controlling sensory stimuli), while avoiding actions that increase intra-abdominal or intrathoracic pressure.