Question

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply.

1.Clustering nursing activities 2.Hyperoxygenating before suctioning
3.Maintaining 20 degree flexion of the knees
4.Maintaining the head and neck in midline position
5.Maintaining the head of the bed (HOB) at 30 degrees elevation

Answer 1

To manage increased intracranial pressure (ICP) after a stroke, important nursing activities include clustering nursing activities, hyperoxygenating before suctioning, maintaining the head and neck in a midline position, and elevating the head of the bed to 30 degrees.

The nurse caring for a client at risk for increased intracranial pressure (ICP) after a stroke can assist with preventing increases in ICP by performing several key activities. Among the options provided, the activities that will help to manage ICP include:

• Clustering nursing activities - to minimize the frequency of disturbances and allow for longer rest periods.
• Hyperoxygenating before suctioning - to prevent decreases in oxygen levels that could potentially increase ICP.
• Maintaining the head and neck in a midline position - to promote venous drainage from the brain and avoid jugular vein compression.
• Maintaining the head of the bed (HOB) at 30 degrees elevation - to facilitate venous return and reduce ICP.

Activity 3, maintaining 20 degree flexion of the knees, is not typically recommended as it can hinder venous return from the legs and potentially increase ICP.

So, the optimal care for patients at risk of increased ICP involves strategies that promote efficient cerebral blood flow and venous return, reduce cerebral metabolic demands, and avoid actions that can lead to intracranial hypertension.