Question

The nurse will implement which of these nursing interventions for the patient with increased intracranial pressure? SATA

1. Place neck in neutral position.
2. Keep head of the bed angled 10° to 20°.
3. Force fluids up to 2 L/day unless otherwise contraindicated.
4. Teach patient to avoid Valsalva maneuver.
5. Position patient to avoid flexion of hips, waist, and neck.
6. Suction only as necessary, but no longer than 10 seconds.

Answer 1

Key interventions for managing increased intracranial pressure include positioning the neck in a neutral position, elevating the head of the bed, avoiding the Valsalva maneuver, careful positioning to avoid flexion, and prudent suctioning.

Step-by-step explanation:

The nursing interventions for a patient with increased intracranial pressure (ICP) include several practices aimed at reducing pressure and ensuring cerebral perfusion. The appropriate interventions are as follows:

• Place neck in neutral position to facilitate venous drainage.
• Keep head of the bed angled 10° to 20° to promote venous outflow without compromising cerebral perfusion.
• Force fluids up to 2 L/day unless otherwise contraindicated to maintain adequate hydration, although fluid management must be individualised based on each patient's condition.
• Teach patient to avoid Valsalva maneuver, as it can acutely increase intracranial pressure.
• Position patient to avoid flexion of hips, waist, and neck, which can impede venous return and increase ICP.
• Suction only as necessary, but no longer than 10 seconds to avoid provoking a rise in ICP due to the associated negative intrathoracic pressures.