Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement?
a. Elevate the head of the bed 20 to 30 de-grees.
b. Place drip pad or cotton to absorb cere-brospinal fluid (CSF) drainage from the nose or ears.
c. Stimulate the patient to better assess changing level of consciousness (LOC).
d. Reposition the patient frequently for comfort.
A
A patent airway must be secured, and the head raised 20 to 30 degrees with the body in correct alignment. Elevation helps reduce ICP. Neurologic signs are monitored closely. An IV line is inserted for access for diuretic drugs, if needed, and for administration of fluid. IV fluids are infused very slowly to prevent fluid overload that would increase the ICP. Diuretics are used to decrease vascular volume and keep ICP as low as possible. Drip pads, patient stimulation, and changing positions frequently may increase ICP.
You might also like to view...
What example illustrates the conclusion that can be drawn from deductive reasoning?
a. All men are mortal and the Dalai Lama is a man; therefore, the Dalai Lama is mortal. b. The planet Earth orbits the Sun; therefore, all planets orbit the Sun. c. Five marbles taken from the bag are blue; therefore, all marbles from the bag are blue. d. The first five people you met at a work interview were nice; therefore, everyone at this office is nice.
Avoid elevating a casted extremity on a pillow.
Answer the following statement true (T) or false (F)
Which congenital malformations result from multifactorial inheritance (Select all that apply)?
a. Cleft lip b. Congenital heart disease c. Cri du chat syndrome d. Anencephaly e. Pyloric stenosis
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following?
A) Gynecomastia B) Cutaneous spider angiomata C) Caput medusae D) Palmar erythema