A patient with increased intracranial pressure (ICP) is being repositioned. The nurse would incorporate which actions into this intervention? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Inform the patient regarding what is going to occur during the intervention.
2. Reposition the patient every 1 to 2 hours.
3. Accompany each repositioning with passive range-of-motion exercises.
4. Elevate the head of the bed to 30 degrees.
5. Manage the repositioning with slow, smooth, and gentle movements.
1,4,5
Rationale 1: Patients should always be informed about what is going to occur.
Rationale 2: Position changes should be done less frequently for patients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.
Rationale 3: Turning alone can cause an increase of ICP. Care should be spaced over time to avoid this complication.
Rationale 4: The head of the bed should be elevated. The degree depends on the reaction of the patient to the position; 30 degrees is usually appropriate, but this can vary by patient.
Rationale 5: It is especially important that patients with increased ICP be repositioned slowly and with smooth, gentle movements, because rapid changes can cause the pressure to increase.
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