Question

The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient?

-Monitor fluid and electrolyte status carefully.

-Position the patient in a high Fowler's position.

-Administer vasoconstrictors to maintain cerebral perfusion.

-Maintain physical restraints to prevent episodes of agitation.

Answer 1

The primary nursing action for managing a patient with increased ICP is to monitor fluid and electrolyte balance meticulously, ensuring proper cerebral perfusion and avoiding further increases in ICP.

Step-by-step explanation:

When caring for a patient experiencing increased intracranial pressure (ICP), the priority nursing action is to carefully monitor the patient's fluid and electrolyte status. This is crucial because cerebrospinal fluid (CSF) serves to protect the brain by providing the necessary buoyancy to prevent the brain from resting on the skull, which can cause severe headaches, constricted blood flow, and significant damage. To manage ICP effectively, it is also important for the healthcare team, including surgeons and nurses, to review key concerns for the patient's recovery and postoperative care, ensuring close monitoring of the patient's vital signs and neurogenic status.

Maintaining a patient in a controlled environment, such as the ICU, where pressure measurements are invasive but can be closely monitored, is essential. The preferred position for a patient with elevated ICP is not high Fowler's position but rather a position that allows for optimal venous drainage, which may include the head being elevated 30 to 45 degrees, depending on the specific circumstances and doctor's orders. Restraints and vasoconstrictors may be used as part of the treatment plan, but they would not be the initial priority actions.