In a patient after RTA revealed sustained head injury. Following admission to the hospital, a diagnosis of increased intracranial pressure was made. The best nursing intervention appropriate in the care of patients is to?

1. A

   Provide a quiet and bright environment

2. B

   Teach controlled coughing and deep breathing.

3. C

   Encourage the intake of clear fluid

4. D

   Elevating the head 15 to 30 degree

Appeared in: PGIMER Chandigarh NO - 2015

Explanation

• Elevating the head of the bed to 15-30 degrees is a primary, non-invasive nursing intervention to manage increased ICP.
• This position utilizes gravity to facilitate venous drainage from the brain, which decreases the volume of blood in the cranial vault.
• Reducing the intracranial volume directly leads to a reduction in intracranial pressure.
• It is a standard of care for patients with or at risk for cerebral edema and increased ICP following a head injury.

Why Other Options Were Wrong

• Option A: A bright environment provides excessive sensory stimulation, which can increase cerebral metabolism and ICP. A quiet and dimly lit room is the appropriate environment.
• Option B: Coughing significantly increases intrathoracic pressure, which impedes venous return from the head and sharply raises ICP. It must be avoided.
• Option C: Encouraging fluid intake can lead to fluid overload, which can worsen cerebral edema and increase ICP. Fluid balance must be carefully maintained, and sometimes fluids are restricted.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Nursing management of increased intracranial pressure (ICP) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• A nurse's primary role in managing increased ICP is to implement interventions that prevent secondary brain injury from ischemia and herniation.
• Positioning is a simple yet powerful tool. The nurse must ensure not only head elevation but also neutral head and neck alignment, as turning the head to the side can compress jugular veins and raise ICP.
• Continuous monitoring of neurological status (using the Glasgow Coma Scale), vital signs, and ICP readings (if a monitor is in place) is critical to detect deterioration early.

How to Approach the Question

• First, identify the core clinical problem: The patient has increased intracranial pressure (ICP) due to a head injury.
• Next, recall the pathophysiology of ICP. The skull is a fixed box containing brain tissue, blood, and cerebrospinal fluid (CSF). An increase in any of these components raises the pressure.
• Evaluate each option based on its physiological effect on ICP.
• Option A (bright light): Does stimulation increase or decrease ICP? It increases it. So, this is incorrect.
• Option B (coughing): Does coughing increase or decrease pressure in the head? It increases it. So, this is incorrect.
• Option C (encouraging fluids): Can excess fluid worsen brain swelling? Yes. So, this is incorrect.

Concept Tested & Keywords

• Concept Tested: Nursing management of increased intracranial pressure (ICP)
• Stem keywords: head injury, increased intracranial pressure, nursing intervention
• Lead-in keywords: best
• Clinical cues: Patient with a head injury from a road traffic accident (RTA) is a high-risk scenario for developing increased ICP.

Question ID

QcvLiZd1OMXYG3B0kAbJXO

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 34-36, 93-95

E6 Medicine Harrison 22e Part 2 p. 249-251