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. keep the head of the bed elevated to 30 degrees.
b. position the patient with head is lower than the body
c. cluster nursing interventions to provide rest periods.
d. encourage coughing and deep breathing.
e. position the patient with knees and hips flexed.

Answer 1

The best nursing intervention for an unconscious patient with ineffective cerebral tissue perfusion and cerebral tissue swelling is to keep the head of the bed elevated to 30 degrees. This aids in reducing intracranial pressure and improving venous return, enhancing cerebral tissue perfusion. The correct option is a. keep the head of the bed elevated to 30 degrees.

Step-by-step explanation:

Correct Nursing Intervention for Cerebral Tissue Perfusion

When caring for an unconscious patient with ineffective cerebral tissue perfusion and cerebral tissue swelling, appropriate nursing interventions are crucial to manage the condition effectively. The priority in such a scenario is to ensure adequate cerebral perfusion and to reduce intracranial pressure. Each potential nursing intervention aims to address these key aspects of care.

Option A, keeping the head of the bed elevated to 30 degrees, is the suggested intervention to help reduce cerebral edema and increase venous return from the brain. This positioning can diminish intracranial pressure and promote better cerebral blood flow. In contrast, Option B, positioning the patient with the head lower than the body would be contraindicated because it might increase intracranial pressure and thus worsen cerebral edema. Option C, clustering nursing interventions to provide rest periods, helps to limit the frequency of disturbances that can elevate intracranial pressure, but it does not directly assist with the immediate problem of cerebral tissue perfusion. Option D, encouraging coughing and deep breathing is an essential intervention for preventing respiratory complications but may potentially increase intracranial pressure and therefore must be balanced carefully against risks vs. benefits. Finally, Option E, positioning the patient with knees and hips flexed, may also increase intracranial pressure and is not recommended for patients experiencing cerebral swelling.

In summary, the most appropriate nursing intervention listed for managing ineffective cerebral tissue perfusion and cerebral tissue swelling in an unconscious patient is Option A: keep the head of the bed elevated to 30 degrees. This technique is a fundamental aspect of neurocritical care that aids in minimizing secondary injury by addressing the perfusion and intracranial pressure issues.