The nurse is monitoring a patient diagnosed with viral encephalitis who has developed signs of increased intracranial pressure including altered level of consciousness, headache, and vomiting.
Proper positioning (head elevated 30-45 degrees with neutral neck alignment) is the priority for managing increased ICP in encephalitis patients to promote venous drainage and reduce pressure. Other interventions like coughing exercises, Trendelenburg position, or hypotonic fluids can worsen ICP.
심화 해설
Core Nursing Explanation
Key Concept Analysis: This question tests the priority nursing intervention for managing Increased Intracranial Pressure (ICP) in a patient with Viral encephalitis. The pathophysiology involves brain inflammation and edema, which increases the volume inside the rigid skull, leading to elevated pressure. This pressure can compromise cerebral blood flow and brain tissue, potentially leading to herniation and death. The priority is to implement measures that reduce ICP and optimize cerebral perfusion pressure (CPP).
Answer Rationale: Key Point! Elevating the head of the bed 30-45 degrees with the neck in neutral alignment is the priority intervention. This position promotes venous drainage from the brain via the jugular veins, reducing cerebral blood volume and, consequently, ICP. Maintaining a neutral neck prevents kinking of the jugular veins, which would impede drainage and increase ICP. This is a fundamental, non-invasive, and immediate action the nurse can take.
Distractor Analysis:
Watch out for confusion! Option ①, encouraging coughing and deep breathing, is contraindicated. While these are generally good for lung expansion, the Valsalva maneuver (straining) associated with coughing increases intrathoracic pressure, which impedes jugular venous return and can cause a dangerous spike in ICP.
Option ②, Trendelenburg position (head down), is absolutely incorrect for increased ICP. This position increases venous pressure in the head, dramatically worsening cerebral edema and ICP. It is used for hypotension or shock, not for neurological conditions with elevated ICP.
Option ④, administering large volumes of hypotonic IV fluids (e.g., 0.45% NaCl), is dangerous. Hypotonic fluids can shift fluid from the vasculature into brain tissue, exacerbating cerebral edema. Fluid management in increased ICP aims for euvolemia (normal volume status), often using isotonic fluids like 0.9% Normal Saline.
Related Concepts: Managing increased ICP follows the Monro-Kellie doctrine: the skull is a fixed container holding brain tissue, blood, and cerebrospinal fluid (CSF). An increase in one component (like tissue edema from encephalitis) must be compensated by a decrease in another to prevent pressure rise. Nursing care focuses on reducing cerebral blood volume and edema.
임상 시나리오
Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse for Mr. Johnson, a 28-year-old admitted with confusion, fever, and severe headache, later diagnosed with viral encephalitis. During your shift, you note his Glasgow Coma Scale (GCS) score has dropped from 14 to 11, he's increasingly lethargic, and he reports a worsening "bursting" headache. His vital signs show a widening pulse pressure and bradycardia (Cushing's triad—a late sign).
Nursing Intervention Strategy:
- Assessment & Monitoring: Perform frequent neurological checks (GCS, pupil size and reactivity, motor strength). Monitor vital signs for Cushing's triad (hypertension, bradycardia, irregular respirations). Assess for nausea/vomiting and headache.
- Immediate Actions (Priority): Elevate HOB to 30-45 degrees. Ensure the head is midline, not turned or flexed, to maintain jugular venous patency. Administer prescribed osmotic diuretics (e.g., Mannitol) or hypertonic saline to draw fluid out of brain tissue.
- Environment & Care: Maintain a calm, quiet environment to minimize stimulation that could increase ICP. Cluster nursing care to allow for rest periods. Avoid activities that cause straining (Valsalva), such as vigorous suctioning or constipation.
- Patient Safety & Precautions: Implement seizure precautions. When suctioning is necessary (for airway clearance), pre-oxygenate and limit suction passes to
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