Identify eight independent nursing interventions and the rationale for each that would be

Question

used to prevent increased intracranial pressure (ICP) in the first 48 postoperative hours.

What will be an ideal response?

Answer 1

• Elevate the head of bed (HOB) 15 to 30 degrees. Positioning with elevated HOB will promote
venous outflow from the brain and help decrease ICP.
• Maintain head and neck in neutral position (no flexion of neck). This promotes venous blood return
to the heart to reduce cerebral congestion and decrease ICP.
• Ensure that endotracheal tube ties do not compress the jugular vein. This promotes venous blood
return and reduces cerebral congestion.
• Limit endotracheal suctioning to no longer than 15 seconds.
• Reposition him at regular intervals. Log roll him to avoid flexion at the hip or knees. This type of
flexion can cause a Valsalva maneuver, increasing ICP.
• Provide a quiet and soothing environment. Control environmental stimuli (noise, temperature,
light, odors). A quiet environment reduces meningeal irritation and promotes pain control; both
reduce ICP.
• Speak softly, explain procedures before touching to avoid startling, and avoid jarring the bed. Try
to limit painful procedures; avoid tension on tubes (e.g., urinary catheter); and consider limiting
pain-stimulation testing. Avoid unnecessary touching.
• Provide passive range-of-motion exercises. This prevents increases in intra-abdominal and
intrathoracic pressures that could raise ICP.
• Space care activities to allow for periods of rest. Do not cluster nursing activities that might
increase ICP.
• Help maintain the patient's body temperature within normal limits by giving prescribed
antipyretics, regulating the temperature of the environment, limiting the use of blankets, keeping
the patient's trunk warm to prevent shivering, and administering tepid sponge baths or using
a hypothermia blanket or convection cooling units to reduce fever. Hyperthermia aggravates
hypoxia and can increase ICP.