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Zorluk: ZorBasic Care and Comfort

A nurse is planning a bed bath and a linen change for a client who is 12 hours post-operative following a craniotomy and is currently being managed for increased intracranial pressure (ICP). Which of the following actions should the nurse implement to ensure client safety and comfort?

  1. Enlist the assistance of another staff member to logroll the client while maintaining the head and neck in a neutral, midline alignment.Cevap
  2. B
    Flex the client's hips and knees to a 90-degree angle while turning to provide stability and access for perineal care.
  3. C
    Lower the head of the bed to a completely flat position temporarily to prevent shearing forces while sliding the clean linens.
  4. D
    Delegate the assessment of the client's posterior skin integrity to the Unlicensed Assistive Personnel (UAP) during the bath.

Cevap

The nurse should enlist assistance to logroll the client, ensuring the head and neck are kept in a neutral, midline position to promote venous drainage.
The correct action is to logroll the client with assistance, keeping the head and neck in a neutral, midline position. In a client with increased intracranial pressure (ICP) following a craniotomy, preventing neck flexion or rotation is critical. A neutral neck alignment ensures that the jugular veins remain uncompressed, allowing for continuous and optimal venous drainage from the brain. This prevents dangerous elevations in ICP that can occur during turning and hygiene care.

Adım Adım Çözüm

1
Analyze the client's clinical status and risks.
The client is post-craniotomy and at risk for further increases in intracranial pressure (ICP).
Identifying the primary risk dictates the constraints on physical movement and positioning during hygiene care.
2
Evaluate the impact of physical positioning on ICP.
Actions that obstruct jugular venous return (neck flexion/rotation) or increase intrathoracic/intra-abdominal pressure (hip flexion, flat position) must be avoided.
Cerebral blood volume and ICP are directly influenced by the efficiency of venous drainage from the head.
3
Select the hygiene intervention that aligns with neurological safety parameters.
Logrolling with assistance and keeping the head neutral is the only option that safely accommodates the need for hygiene while preventing ICP spikes.
This method prevents twisting of the cervical spine, thereby protecting the jugular veins from compression.

Anahtar Kavram

Basic care and positioning for clients with increased intracranial pressure (ICP)
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Konular

Basic Care and Comfort

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