A 52-year-old client is recovering in the intensive care unit four hours after a right supratentorial craniotomy. The client is lethargic but responds appropriately to verbal commands. Recent assessment reveals a blood pressure of 138/82 mm Hg, an apical pulse of 84 bpm, and a respiratory rate of 14 breaths per minute. Which intervention should the nurse implement to minimize the risk of increased intracranial pressure?
- Elevate the head of the bed to 30 degrees while maintaining the neck in a neutral, midline alignmentAnswer
- BPosition the client flat in a lateral decubitus alignment with the hips and knees sharply flexed
- CInstruct the client to perform forceful coughing exercises at hourly intervals to ensure airway clearance
- DCollaborate with the respiratory therapist to target a partial pressure of carbon dioxide (PaCO2) between 45 and 50 mm Hg
Answer
Elevate the head of the bed to 30 degrees while maintaining the neck in a neutral, midline alignment
Maintaining the head of the bed at a 30-degree angle with the neck in a neutral, midline position is a critical intervention following intracranial surgery. This specific alignment promotes optimal venous drainage from the brain through the jugular veins, preventing blood from pooling in the cranial vault and thereby minimizing the risk of increased intracranial pressure.
Step-by-Step Solution
Key Concept
Prevention of Increased Intracranial Pressure