List eight independent nursing measures and the rationale for the use of each that nurses

Question

implement to decrease or control increased ICP in closed head injury.

What will be an ideal response?

Answer 1

• Elevate the head of bed (HOB) 15 to 30 degrees. Positioning with elevated HOB will promote
venous outflow from the brain and help decrease ICP.
• Maintain head and neck in neutral position (no flexion of neck). This promotes venous blood return
to the heart to reduce cerebral congestion and decrease ICP.
• Ensure that tracheostomy, endotracheal tube ties, or O2 tubing does not compress the jugular vein.
This promotes venous blood return and reduces cerebral congestion.
• Limit endotracheal suctioning to no longer than 15 seconds.
• Reposition patient at regular intervals. Log roll the patient to avoid flexion at the hip or knees. This
type of flexion can cause a Valsalva maneuver, increasing ICP.
• Administer stool softeners as needed to prevent constipation. Preventing straining with bowel
movements reduces the risk of performing the Valsalva maneuver.
• Provide a quiet and soothing environment. Control environmental stimuli (noise, temperature,
light, odors). A quiet environment reduces meningeal irritation and promotes pain control; both
reduce ICP.
• Speak softly, explain procedures before touching to avoid startling, and avoid jarring the bed. Try
to limit painful procedures, avoid tension on tubes (e.g., urinary catheter), and consider limiting
pain-stimulation testing. Avoid unnecessary touching.
• Try to avoid situations in which the patient might become emotionally upset. Limit visitors as
necessary.
• Provide passive range-of-motion (ROM) exercises. This prevents increases in intra-abdominal and
intrathoracic pressures that could raise ICP.
• Space patient care activities to allow for periods of rest. Do not cluster nursing activities that might
increase ICP.
• Help maintain patient's body temperature within normal limits by giving prescribed antipyretics,
regulating temperature of the environment, limiting use of blankets, keeping patient's trunk warm
to prevent shivering, and administering tepid sponge baths or using hypothermia blanket or
convection cooling units to reduce fever. Hyperthermia aggravates hypoxia and can increase ICP.