# A 10-year-old child is admitted to the pediatric intensive care unit following a severe head injury from a fall from a tree. The child has an intracranial pressure (ICP) monitor in place and is receiving mechanical ventilation. The nurse notes that the ICP reading has increased from 12 mmHg to 22 mmHg over the past hour. Which nursing intervention should the nurse implement first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542406  
> language: ko  
> subject: Child Health

## 문제

A 10-year-old child is admitted to the pediatric intensive care unit following a severe head injury from a fall from a tree. The child has an intracranial pressure (ICP) monitor in place and is receiving mechanical ventilation. The nurse notes that the ICP reading has increased from 12 mmHg to 22 mmHg over the past hour. Which nursing intervention should the nurse implement first?

Priority nursing intervention for increased intracranial pressure in a pediatric patient

## 보기

1. Elevate the head of the bed to 30 degrees and ensure proper neck alignment **✔ 정답**
2. Administer prescribed mannitol intravenously as ordered
3. Increase the rate of mechanical ventilation to promote hyperventilation
4. Notify the physician immediately about the ICP increase

**정답: 1**

## 해설

Elevating the head of the bed to 30 degrees with proper neck alignment is the immediate first-line intervention for increased ICP as it promotes venous drainage and reduces intracranial pressure. Other options require physician orders or careful monitoring and are not the nurse's first independent action.

## 심화 해설

Clinical Judgment
This question evaluates the nurse's prioritization in the emergency situation of increased intracranial pressure. The key point is that the ICP has risen from 12 to 22 mmHg. This is an abnormal value, which threatens cerebral perfusion pressure (CPP) and poses a risk of secondary brain injury. The nurse must decide between independent interventions and reporting to the physician. Elevating the head of the bed (30 degrees) and maintaining neck alignment are the safest and most effective first-line interventions that the nurse can perform immediately and independently. This is a physical method that promotes venous outflow to lower ICP, buying valuable time while preparing other treatments. Notifying the HCP is also important, but there are life-saving interventions that can be performed first before reporting.

Memory Tip:
Drainage Before Drugs & Doctors. When ICP rises, the first thing to consider is helping with venous blood drainage from the brain. Position changes serve exactly that role.

KR vs US:
In Korea, there is a culture that strongly emphasizes reporting to the physician, but in NGN/US nursing, the nurse's independent judgment and immediate intervention are valued equally. It is a paradigm of "performing necessary interventions immediately while simultaneously or immediately after reporting" rather than "acting after reporting." Especially in time-sensitive situations like ICP management, the nurse's ability to intervene independently is key.

## 임상 시나리오

Clinical Practice Guide
Pediatric ICP monitoring management: Keep the head of the bed elevated at 30 degrees. Align the neck in a neutral position (no flexion, extension, or rotation) to prevent jugular vein compression. Minimize actions that trigger the Valsalva maneuver (vomiting, coughing, constipation). Monitor ICP trends and calculate CPP (mean arterial pressure - ICP), aiming to maintain it between 50-70 mmHg.

Caution:
Trap points in SATA (Select All That Apply) questions! In a question asking you to choose "all actions to take when ICP increases," the option "notify the physician immediately" is always included, but it is not the "first" thing to do. It is crucial to read the question's directive (priority, first, initial) accurately. Also, while hyperventilation was a common intervention in the past, it is now used restrictively due to the risk of excessively reducing cerebral blood flow.

## 핵심 개념

- **Intracranial Pressure** — Intracranial pressure. Pressure inside the skull. Normal adult is 5-15 mmHg, children are lower (3-7 mmHg). Above 20-25 mmHg is considered an elevation requiring treatment.
- **Cerebral Perfusion Pressure** — Cerebral perfusion pressure. The net pressure that supplies blood to the brain. CPP = mean arterial pressure (MAP) - ICP. Generally targeted at 50-70 mmHg to maintain adequate cerebral perfusion.
- **Monro-Kellie Doctrine** — The volume inside the skull is fixed, and if the volume of one of the brain tissue, blood, or cerebrospinal fluid increases, the volume of one or both of the others must decrease to prevent pressure from rising. This is the pathophysiological basis of increased ICP.
- **Mannitol** — Osmotic diuretic. Increases intravascular osmotic pressure to draw water from brain tissue into the blood vessels, reducing cerebral edema and ICP. Requires monitoring of renal function and electrolyte imbalance.
- **Hyperventilation** — Hyperventilation. Increasing the respiratory rate to lower the blood carbon dioxide level (PaCO2). A low PaCO2 causes cerebral vasoconstriction, reducing cerebral blood flow and blood volume, which temporarily lowers ICP. Long-term use carries a risk of cerebral ischemia.

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