A client with increased intracranial pressure (ICP) is being repositioned. The nurse performs this intervention incorporating which of the following? Select all that apply
1. Manage the repositioning with slow, smooth, and gentle movement.
2. Inform the client regarding what is going to occur during the intervention.
3. Elevate the head of the bed to 30 degrees.
4. Accompany each repositioning with passive range-of-motion exercises.
5. Reposition the client every 1 to 2 hourss.
1. Manage the repositioning with slow, smooth, and gentle movement.
2. Inform the client regarding what is going to occur during the intervention.
3. Elevate the head of the bed to 30 degrees.
Rationale: Manage the repositioning with slow, smooth, and gentle movement. It is especially important that clients with increased ICP should be repositioned slowly and with smooth, gentle movements, because rapid changes can cause the pressure to increase. Inform the client regarding what is going to occur during the intervention. Clients should always be informed about what is going to occur. Elevate the head of the bed to 30 degrees. The head of the bed should be elevated. The degree depends on the reaction of the client to the position; 30 degrees is usually appropriate, but this can vary by the client. Accompany each repositioning with passive range-of-motion exercises. Position changes should be done less frequently for clients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP. Reposition the client every 1 to 2 hourss. Position changes should be done less frequently for clients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.
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