Question

A nurse on the intensive care unit is caring for a patient who has severe brain injury and a cerebral perfusion pressure (CPP) of 59mmHg. Which of the following actions should the nurse take?

A. Provide warming measures for the client
B. Hyperextend the client's neck
C. Flex the client's hip
D. Adjust the client's head of bed

Answer 1

In a patient with severe brain injury and a CPP of 59 mmHg, the nurse should adjust the patient's head of bed to possibly improve the cerebral perfusion pressure.

Step-by-step explanation:

The cerebral perfusion pressure (CPP) is crucial for maintaining adequate blood flow to the brain, ensuring that the brain tissue receives the oxygen and nutrients it needs. In the care of a patient with severe brain injury and a CPP of 59 mmHg, it is imperative for the nurse to take steps to maintain or improve CPP to prevent further brain damage. The recommended action for the nurse in this scenario would be D. Adjust the client's head of bed.

Raising the head of the bed can help decrease intracranial pressure by promoting venous drainage, which in turn can help improve the CPP. However, this should be done carefully and increments to ensure the action does not decrease the blood pressure too much which may lower the CPP. It is important to avoid hyperextending the patient's neck or flexing the hips as these positions can increase intracranial pressure. Warming measures are not directly related to managing CPP.