The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP). Which nursing interventions help reduce ICP? Select all that apply.

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Most nursing activities increase intracranial pressure (ICP) in brain injuries. The goal is to reduce ICP while managing basic client needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes. Metabolic demands (eg, pain, straining, agitation, shivering, fever, hypoxia) increase brain blood supply and raise ICP. Nursing interventions to control ICP include: Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion (Option D) Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver) Managing pain well while monitoring sedation Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise) (Option C) Ensuring adequate oxygenation Hyperventilating and preoxygenating the client before suctioning; reducing CO₂ (a potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP (Option B) (Option A) Stimulation increases oxygen metabolism within the brain, increasing the risk for irreversible brain damage in increased ICP. Limit performing interventions unless absolutely necessary and avoid performing interventions in clusters. (Option E) The nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP. Educational objective: Nursing activities can increase intracranial pressure (ICP) and should be limited and spread throughout the day. The goal is to reduce ICP while managing basic needs. Nursing interventions include elevating the head of the bed, administering stool softeners, managing pain and fever, and maintaining a calm environment.

The Nurse Cares for an Intubated Client on Mechanical Ventilation