Following admission to the hospital, a diagnosis of increasing intracranial pressure was made. The nursing intervention appropriate in the care of this client is to:

Appeared in: AIIMS Delhi NO - 2018

Explanation

Elevating the head of the bed to 15-30 degrees is a primary nursing intervention to manage increased intracranial pressure (ICP).
This position uses gravity to promote venous drainage from the head, which helps to lower the pressure inside the skull.
It is crucial to balance this with maintaining adequate cerebral perfusion pressure (CPP), as excessive elevation can lower blood pressure and reduce blood flow to the brain.
The head should also be kept in a neutral, midline position to avoid kinking the jugular veins, which would impede venous outflow.

Option A: Coughing, like the Valsalva maneuver, increases intrathoracic pressure. This impedes venous return from the brain and directly increases intracranial pressure, which is harmful to the patient.
Option B: A brightly lit environment provides excessive sensory stimulation. For a patient with increased ICP, this can cause agitation, restlessness, and an increase in metabolic demand, all of which can elevate ICP.
Option D: Encouraging fluid intake can lead to fluid overload and hemodilution. This can worsen cerebral edema, the swelling of brain tissue, which is a primary cause of increased ICP. Fluid management usually involves restriction or careful titration.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing Management of Increased Intracranial Pressure (ICP) to guide bedside assessment, documentation, and the next nursing action.
Proper positioning is a simple, non-invasive, yet critical nursing action to manage ICP and prevent secondary brain injury.
Nurses must continuously monitor for activities that increase ICP, such as suctioning, turning, and family visits, and cluster care to provide periods of rest.
Patient safety is paramount. Any intervention that could potentially raise ICP, like straining or excessive stimulation, must be actively avoided and managed.

How to Approach the Question

First, identify the core issue in the question: the patient has 'increasing intracranial pressure'.
Next, recall the pathophysiology of ICP. The skull is a fixed box, so any increase in the volume of brain, blood, or cerebrospinal fluid will increase pressure.
Evaluate each option based on its physiological effect on ICP.
Option A (coughing): This increases intrathoracic pressure, which raises ICP. Eliminate this.
Option B (bright light): This is a form of stimulation that can increase brain activity and ICP. Eliminate this.
Option C (head elevation): This uses gravity to help drain venous blood from the head, reducing ICP. This is a standard, correct intervention.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 34-36, 37-39

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