The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?
Suction the patient to minimize secretions
Continue with the assessment and document the finding
Notify the physician and raise HOB to 35-45 degrees
Lower the head of the bed and pad the side rails
The Correct Answer is C
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
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