The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?
Explanation & Rationale
A. Elevate the head of the bed and provide a pillow under the client's head. While elevating the head of the bed to 30 degrees can help reduce ICP by promoting venous drainage, placing a pillow under the head may cause neck flexion, which can obstruct venous outflow and worsen intracranial pressure. Instead, the head should be maintained in a neutral midline position without excessive flexion or extension. B. Suction the endotracheal tube every 15 minutes to reduce choking. Frequent suctioning can increase ICP due to coughing and vagal stimulation. Suctioning should be performed only as needed and using minimized suction duration to prevent sudden rises in intracranial pressure. C. Intersperse treatments and nursing care with frequent rest periods. Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases. D. Change positions frequently while providing basic nursing care. Frequent repositioning can cause sudden fluctuations in ICP, especially if movements are abrupt or cause venous obstruction. Turning the client slowly and maintaining the head in a neutral position is recommended to avoid exacerbating intracranial hypertension.