The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

Maintain the patient’s head of bed at 30° to ensure accuracy of intracranial pressure monitoring. The plan of care for the patient with severely elevated intracranial pressure (ICP) should include maintaining the patient’s head of bed at 30° to ensure accuracy of ICP monitoring as well as promote drainage of CSF. Placing the patient prone is contraindicated because it interferes with CSF drainage and can worsen ICP. Rectal temperatures and unnecessary deep endotracheal suctioning should be avoided because it can cause the patient to Valsalva and further increase ICP. The patient’s endotracheal tube should be suctioned as necessary (rather than scheduled).

The patient who has severely elevated intracranial pressure follo...

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Physiological Adaptation
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Category: Physiological Adaptation
Difficulty: 6

Topics: Communication & Documentation Neurology Intracranial Regulation Nursing Interventions

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