A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
A.
Use log rolling to reposition the client.
B.
Place a warming blanket on the client.
C.
Instruct the client to cough and deep breathe.
D.
Place the client in a supine position.
The correct answer and Explanation is :
The correct action for a nurse caring for a client with increased intracranial pressure (ICP) following a closed-head injury is:
A. Use log rolling to reposition the client.
Explanation:
Increased intracranial pressure (ICP) is a serious condition that can occur after a head injury, and it requires careful management to prevent worsening of the condition. Here’s why option A is the most appropriate:
- Log Rolling Technique: When repositioning a client with increased ICP, it’s crucial to avoid actions that might increase ICP or cause further injury. The log rolling technique is a method used to reposition patients while maintaining spinal alignment. This technique minimizes the risk of increasing ICP by avoiding abrupt movements and excessive flexion or extension of the neck and spine. It ensures that the head and neck are kept in a neutral position during the repositioning process, which is essential for minimizing intracranial pressure.
- Avoiding Coughing and Deep Breathing: Options C and D are not appropriate. Coughing and deep breathing can increase ICP because they increase intrathoracic pressure, which can transmit to the intracranial space. Instructing the client to cough and deep breathe might exacerbate the condition and should generally be avoided unless specifically directed by a healthcare provider.
- Warming Blanket: Option B, placing a warming blanket on the client, is not indicated for managing increased ICP. The primary concern is to avoid any interventions that could potentially raise the ICP. While maintaining normothermia is important, a warming blanket could potentially cause discomfort or exacerbate other issues, such as increased metabolic demands, which are not ideal for a client with elevated ICP.
- Supine Positioning: Option D is also incorrect. The supine position can sometimes increase ICP, particularly if it leads to poor head alignment or venous drainage issues. The head of the bed is typically kept elevated (usually 30 degrees) to promote venous return and decrease ICP, rather than keeping the client in a supine position.
In summary, log rolling (Option A) is the safest method for repositioning a client with increased ICP as it minimizes risk and helps maintain proper spinal alignment.