Question

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

(Option 1) Documentation is important, but it is not the priority action.

(Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure.

(Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting.

Educational objective:
Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

Answer 1

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in clients with a history of increased ICP. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. Raising the head of the bed to 30 degrees can help with draining cerebrospinal fluid without lowering cerebral blood pressure.

Step-by-step explanation:

Unexpected and projectile vomiting without nausea can be a sign of increased ICP (intracranial pressure), especially in clients with a history of increased ICP. The vomiting is related to pressure changes in the cranium and is often associated with a headache that worsens with a lowered head position. The most appropriate action in this situation is to obtain a full set of vital signs and immediately contact the healthcare provider (HCP).

It is important to note that documentation is important but not the priority action in this case. Instead of lowering the head, the head of the bed should be raised to 30 degrees for clients with suspected increased ICP to help drain the cerebrospinal fluid without lowering the cerebral blood pressure.

The vomiting caused by increased ICP is not related to nausea and may not respond well to anti-nausea medications. Decreasing intracranial pressure will help relieve the vomiting.