Question

The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage. What should the nurse do? Select all that apply.

1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.

Answer 1

The nurse should elevate the head of the bed 15 - 20 degrees, contact the HCP if ICP exceeds 15 mmHg, and monitor neurological status using tools like the Glasgow Coma Scale while avoiding coughing and active range-of-motion exercises after brain surgery.

Step-by-step explanation:

The nurse should take the following steps when caring for a patient with potential brain injury and increased intracranial pressure (ICP):

• Elevate the head of the bed 15 - 20 degrees to aid in reducing ICP.
• Contact the healthcare provider (HCP) if ICP is greater than 15 mmHg, as 20 to 25 mmHg are the upper limits of normal ICP.
• Monitor neurologic status, preferably using standardized tools such as the Glasgow Coma Scale.

Coughing and active range-of-motion exercises should be avoided in the early postoperative stages as they can increase ICP.