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A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?
- A. Keep the head of the bed elevated to 30 degrees.
- B. Position the patient with the knees and hips flexed.
- C. Encourage coughing and deep breathing to improve oxygenation.
- D. Cluster nursing interventions to provide uninterrupted rest periods.
Correct Answer: A
Rationale: The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
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The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.
The nurse is caring for a patient who is unconscious with a traumatic head injury and has a blood pressure of 72 mm Hg, and an intracranial pressure of 22 mm Hg. What is the cerebral perfusion pressure (CPP)?
- A. 50 mm Hg
- B. 94 mm Hg
- C. 72 mm Hg
- D. 22 mm Hg
Correct Answer: A
Rationale: The formula for cerebral perfusion pressure (CPP) is CPP = MAP - ICP, where MAP (mean arterial pressure) is calculated as (SBP + 2*DBP)/3. Given BP of 72 mm Hg (assuming this is the MAP as the question implies a single value), and ICP of 22 mm Hg, CPP = 72 - 22 = 50 mm Hg.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
- A. Elevate the head of the patient's bed to 60 degrees.
- B. Document the BP and ICP in the patient's record.
- C. Report the BP and ICP to the health care provider.
- D. Continue to monitor the patient's vital signs and ICP
Correct Answer: C
Rationale: The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP = MAP - ICP). This is below the normal range of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
The nurse is suctioning a patient with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?
- A. Document the increase in intracranial pressure.
- B. Assume that the patient's neck is not in a flexed position.
- C. Notify the health care provider about the change in pressure.
- D. Increase the rate of the prescribed propofol infusion.
Correct Answer: B
Rationale: Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation, there is no indication that anxiety has contributed to the increase in intracranial pressure.
The nurse is caring for a patient who is disoriented and anxious as a result of increased intracranial pressure. Which of the following nursing actions should be included in the plan of care?
- A. Encourage family members to remain at the bedside.
- B. Apply soft restraints to protect the patient from injury.
- C. Keep the room well lighted to improve patient orientation.
- D. Minimize contact with the patient to decrease sensory input
Correct Answer: A
Rationale: Patients with disorientation as a result of increased ICP will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.