A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.)
a. administration of sedatives concurrently with neuromuscular blockade.
b. dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day.
c. ensuring that deep vein thrombosis prophylaxis is initiated.
d. providing interventions for eye care, oral care, and skin care.
A, C, D
Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate.
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