A nurse is caring for a patient with increased intracranial pressure (ICP) who has an ICP monitor in place with current readings of 22 mmHg. Which nursing intervention should be the priority to prevent further elevation of ICP?

The nurse is monitoring a patient with a traumatic brain injury who has an ICP monitor in place with current readings of 22 mmHg.

1 Maintain the head of the bed elevated at 30 degrees with the head in neutral alignment ✓ 정답
2 Administer prescribed mannitol 1 g/kg IV bolus immediately
3 Perform frequent neurological assessments every 15 minutes
4 Encourage deep breathing and coughing exercises to prevent pneumonia

해설

Maintaining head elevation at 30 degrees with neutral alignment is the priority to prevent ICP elevation by promoting venous drainage. Mannitol requires prescription, neurological assessments are monitoring, and coughing exercises can increase ICP.

같은 주제 다음 문제A nurse is assessing a patient with suspected increased intracranial pressure (ICP). Which…

심화 해설

Clinical Context
The patient's intracranial pressure (ICP) reading is 22 mmHg, which exceeds the normal threshold of

임상 시나리오

ICP Crisis: Positioning PriorityImmediate non-pharmacologic intervention for ICP >20 mmHg

When ICP reads 22 mmHg, the first-line nursing action is to elevate the head of bed to 30 degrees and maintain the head in a neutral midline alignment. This promotes jugular venous drainage and facilitates cerebrospinal fluid flow, immediately reducing intracranial volume.

Avoid hip flexion or bending the neck, as these can compress jugular veins and increase ICP. Ensure the cervical collar is not too tight if one is in place. This positioning optimizes cerebral perfusion pressure (CPP) by maximizing venous outflow without compromising arterial inflow.

Caution

Do not encourage coughing or deep breathing exercises during acute ICP elevation. These activities mimic the Valsalva maneuver, increasing intrathoracic pressure, reducing venous return from the brain, and causing a dangerous spike in ICP.

핵심 개념

Intracranial Pressure (ICP) — The pressure inside the skull exerted by brain tissue, blood, and cerebrospinal fluid; normal range is 5-15 mmHg.
Cerebral Perfusion Pressure (CPP) — The pressure gradient driving cerebral blood flow, calculated as Mean Arterial Pressure (MAP) minus ICP; target is typically >60-70 mmHg.
Mannitol — An osmotic diuretic used to draw fluid from brain tissue into the vascular space, reducing cerebral edema and ICP.
Jugular Venous Drainage — The primary route for venous blood to exit the brain; optimizing head position enhances outflow and reduces intracranial volume.
Valsalva Maneuver — Forced expiration against a closed glottis (e.g., coughing, straining) that increases intrathoracic pressure and can dangerously elevate ICP.

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A nurse is caring for a patient with increased intracranial pressure (ICP) who has an ICP monitor in place with current readings of 22 mmHg. Which nursing intervention should be the priority to prevent further elevation of ICP?

심화 해설

임상 시나리오

핵심 개념

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