The nurse is planning care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient?
1. Encourage family and physician to discuss patient's care and prognosis in the patient's room.
2. Assess for daily bowel movement and provide intervention as appropriate.
3. Maintain head of bed at a 15-degree angle with knee elevation.
4. Cluster care activities.
2
Rationale 1: Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team.
Rationale 2: When a patient engages in a Valsalva maneuver when straining with a bowel movement or pushing up in bed, the ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining.
Rationale 3: The head of the bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation.
Rationale 4: The patient's ICP may rise when nursing activities are delivered in a traditional "cluster" fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patient's ICP should be permitted to return to baseline before continuing with other activities.
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