Question

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

a. Document the increase in intracranial pressure.
b. Ensure that the patient's neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.

Answer 1

The nurse should first ensure that the patient's neck is in a neutral position after an increase in intracranial pressure. Other actions such as documentation, notification, and medication adjustment follow based on the patient's ongoing assessment.

Step-by-step explanation:

The student has asked about the appropriate first action for a nurse to take after noticing an increase in intracranial pressure (ICP) from 14 to 17 mm Hg following endotracheal suctioning in a patient with a traumatic head injury. The nurse should first ensure that the patient's neck is in a neutral position, as improper positioning can increase ICP. Documenting the increase, notifying the healthcare provider, and adjusting medication can be subsequent actions based on the initial response and the patient's condition. To provide context on the importance of monitoring and managing ICP, it's essential to understand that the normal ICP range is 5 to 12 mm Hg. Elevations in ICP can lead to brain injury and should be addressed promptly. For example, a gauge pressure in the cerebrospinal fluid can cause the skull to grow abnormally large in infants if it rises significantly above normal levels. Understanding the physics behind these biological processes can help in clinical decision-making and patient care.