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The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?
It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.
The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be
A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.
When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes,
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushings triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.
Components of the GCS the nurse would use to assess a patient after a head injury include
Primary prevention strategies to reduce the occurrence of head injuries would include
The nurse preparing to care for a patient after a suspected stroke would question an order for a(n)