Which nursing interventions will help prevent sharp spikes in ICP and surgical hemorrhage?
a. Keep the head of the bed elevated 45 to 90 degrees.
b. Administer an antiemetic to prevent vomiting.
c. Provide fluid restriction.
d. Help with turn, cough, and deep breathe exercises.
B
Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) and possibly surgical hemorrhage. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions, using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced. Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities.
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