The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness
Monitoring reveals that the patient's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action?
A) Position the patient in the high Fowler's position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion pressure.
D) Prepare the patient for craniotomy.
Ans: C
Feedback:
The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patient's condition.
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