The nurse is caring for a patient four hours after intracranial surgery. Which of the following actions should the nurse take immediately?
1. Turn, cough, and deep-breathe the patient.
2. Place the patient with the neck flexed and head turned to the side.
3. Perform passive range of motion exercises.
4. Move client to the head of the bed using a turning sheet.
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The Correct Answer to the Question above is:(4)
Reworded question: What is a priority after intracranial surgery?
Strategy: Determine the outcome of each answer choice.
Needed Info:
Monitor vital signs hourly. Elevate head 15 to 30 degrees to promote venous drainage from brain. Avoid neck flexion and head rotation (support in cervical collar or neck rolls). Reduce environmental stimuli. Prevent the Valsalva maneuver; teach client to exhale while turning or moving in bed. Administer stool softeners. Restrict fluids to 1,200-1,500 ml/day. Administer medications: osmotic diuretics, corticosteroid therapy, and anticonvulsant meds.
Category: Implementation/Physiological Integrity
(1) Turn, cough, and deep-breathe the patient—coughing is discouraged, can increase intracranial pressure (2) Place the patient with the neck flexed and head turned to the side—will increase ICP; keep head in a neutral position (3) Perform passive range of motion exercises—changes in patient's position can increase intracranial pressure (4) Move client to the head of the bed using a turning sheet—CORRECT: patient's body should be moved as a unit to prevent increased ICP; prevent disruption of the ICP monitoring system
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