Question

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

A. Encourage coughing and deep breathing.
B. Position the patient with knees and hips flexed.
C. Keep the head of the bed elevated to 30 degrees.
D. Cluster nursing interventions to provide rest periods.

Answer 1

The most appropriate nursing intervention for a patient who is unconscious with ineffective cerebral tissue perfusion and cerebral tissue swelling is to keep the head of the bed elevated to 30 degrees. This helps alleviate cerebral tissue swelling by facilitating venous drainage and reducing intracranial pressure.

Step-by-step explanation:

A patient who is unconscious with ineffective cerebral tissue perfusion and cerebral tissue swelling requires very specific nursing interventions to help reduce the intracranial pressure and maintain adequate cerebral perfusion. Among the given options, the most appropriate nursing intervention would be C. Keep the head of the bed elevated to 30 degrees. This position helps reduce intracranial pressure and facilitates venous drainage, which can help alleviate cerebral tissue swelling.

It is essential to understand that interventions such as encouraging coughing and deep breathing, while beneficial in some cases, may actually increase intracranial pressure in this particular scenario, which is not desirable. Flexing the patient's knees and hips should also be avoided as it could obstruct venous return from the lower extremities. Finally, clustering nursing interventions would indeed allow for rest periods, but the priority here is to manage cerebral edema and ensure adequate brain perfusion.