Question

The nurse is preparing to change the body position of a patient with increased intracranial pressure (ICP). Which factors should the nurse consider prior to changing the position? Select all that apply.

-Placing the patient in side-lying position

-Raising the head of bed above 30 degrees

-Maintaining a head-up position for the patient

-Taking care to prevent extreme neck flexion of patient

-Adjusting the patient's body position to decrease intracranial pressure (ICP)

Answer 1

The nurse should consider raising the head of the bed above 30 degrees, maintaining a head-up position, and preventing extreme neck flexion when changing the position of a patient with increased ICP.

Step-by-step explanation:

When preparing to change the body position of a patient with increased intracranial pressure (ICP), the nurse should consider several factors to ensure patient safety and mitigate further increase in ICP.

• Raising the head of the bed above 30 degrees can help decrease intracranial pressure by promoting venous drainage, thus reducing blood volume in the cranial vault.
• Maintaining a head-up position for the patient can also support the reduction of ICP through gravity-assisted drainage.
• Preventing extreme neck flexion is critical as this can impede venous outflow, potentially increasing intracranial pressure.

In addition, placing the patient in a side-lying position and adjusting the patient's body position can be crucial, but these must be done carefully, considering the potential effects on the patient's ICP and overall stability.