A 42-year-old client is admitted to the trauma unit following a motor vehicle collision. The client is diagnosed with a basilar skull fracture and has clear fluid leaking from the right ear. The client is lethargic but arousable, reporting a severe, throbbing headache. The nurse reviews the client's arterial blood gas (ABG) results obtained on room air:
| Measurement | Result |
|---|---|
| pH | 7.31 |
| PaCO₂ | 52 mm Hg |
| HCO₃⁻ | 25 mEq/L |
| PaO₂ | 78 mm Hg |
To reduce the risk of life-threatening physiological decompensation, which of the following is the priority nursing action?
- Elevate the head of the bed to 30 degrees and ensure the client's neck is in a neutral, midline position.Cevap
- BAdminister a prescribed as-needed intravenous opioid analgesic to manage the severe headache and reduce metabolic demand.
- CPlace the client in a flat, supine position to maximize cerebral perfusion pressure and prevent ischemic brain injury.
- DGently pack the right ear canal with sterile gauze to absorb the leaking fluid and minimize the risk of ascending meningitis.
Cevap
Elevate the head of the bed to 30 degrees and ensure the client's neck is in a neutral, midline position.
The client's ABG results indicate uncompensated respiratory acidosis with significant hypercapnia (PaCO₂ 52 mm Hg). Elevated carbon dioxide is a potent cerebral vasodilator that increases cerebral blood flow and intracranial pressure (ICP). In a client with a head injury, such as a basilar skull fracture with a cerebrospinal fluid leak, this hypercapnia greatly increases the risk of brain herniation. Elevating the head of the bed to 30 degrees and maintaining the neck in a neutral, midline position promotes jugular venous drainage, which is the priority, evidence-based action to mechanically reduce ICP and prevent physiological decompensation.
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Anahtar Kavram
Management of increased intracranial pressure in the setting of acute hypercapnia and basilar skull fracture.
Tahmini Süre:1m 30s