A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up posi-tion to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
You might also like to view...
The nurse is preparing to administer a subcutaneous injection and notes that the previous injection was given to the lateral aspect of the upper arm. Which of these sites would be the MOST appropriate choice to administer this dose?
a. anterior forearm c. upper chest b. anterior thigh d. dorsogluteal
A resident has the following items on her meal tray. Which is counted as fluid intake?
a. Butter b. Gravy c. Soup d. Applesauce
Wrinkles in a binder can
A) cause pressure ulcers. B) cause reddened areas on the patient's skin. C) cause the patient discomfort. D) all of the above
Aspirin intake carries an increased risk of
A. headache pain 2 B. gastric bleeding C. vaginal bleeding D. increased blood clotting