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Difficulty: HardBasic Care and Comfort

A nurse is planning hygiene and comfort measures for a client with a severe traumatic brain injury and continuously monitored increased intracranial pressure (ICP). The client is mechanically ventilated and requires a full bed bath, linen change, and repositioning. Which of the following nursing interventions is the most appropriate?

  1. A
    Rotate the client's head to a lateral position to facilitate thorough cleansing of the posterior neck and scalp.
  2. B
    Delegate the bed bath and linen change to the unlicensed assistive personnel (UAP) while the nurse closely observes the ICP monitor.
  3. Coordinate with staff to log-roll the client, maintaining the head in neutral alignment, and provide rest periods between care activities.Answer
  4. D
    Apply bilateral wrist restraints during the hygiene care to prevent sudden reflex movements from compromising the artificial airway.

Answer

The most appropriate action is to coordinate with staff to log-roll the client while maintaining the head in neutral alignment, and to provide rest periods between care activities.
The most appropriate intervention is to log-roll the client while maintaining the head and neck in a neutral, midline alignment. This position prevents the compression of the jugular veins, thereby optimizing venous return from the brain and helping to control intracranial pressure (ICP). Furthermore, spacing out nursing care activities (rather than clustering them) provides necessary rest periods, which prevents the cumulative, sustained spikes in ICP that often accompany prolonged stimulation.

Step-by-Step Solution

1
Analyze the client's clinical condition and priority risks.
The client has a severe traumatic brain injury with increased ICP and is mechanically ventilated. The primary risk is further elevating the ICP during routine care.
Nursing interventions, including basic hygiene and repositioning, can cause dangerous spikes in ICP if not performed with strict neurological precautions.
2
Evaluate the physiological impact of positioning and movement on ICP.
Neck flexion or rotation compresses jugular veins, impeding venous return. Prolonged or clustered nursing activities cause cumulative ICP increases.
Maintaining a neutral midline position and spacing care activities directly mitigates the physiological triggers of ICP elevation.
3
Select the intervention that safely accomplishes hygiene and comfort needs without compromising neurological stability.
Log-rolling with staff assistance ensures neutral alignment, and spacing activities prevents sustained ICP spikes.
This approach balances the client's need for basic care with the critical requirement of preventing secondary brain injury.

Key Concept

Basic care and comfort in clients with increased ICP requires maintaining a neutral, midline head position to optimize venous drainage and clustering care to avoid sustained ICP elevation.
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Basic Care and Comfort

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