ICP monitoring is instituted for a patient with a head injury.The patient's arterial blood pressure is 92/50 mm Hg,and her ICP is 18 mm Hg.Which nursing action is most appropriate?

Question

Quizplus · Accepted Answer

An ICP of 18 mm Hg is considered elevated and outside of normal range. A MAP (mean arterial pressure) of at least 70 mm Hg is required to ensure adequate cerebral perfusion pressure (CPP), and a CPP of less than 60 mm Hg for a prolonged period of time may result in ischemia and neuronal death. Therefore, the nurse should notify the physician about the patient's ICP and blood pressure readings so that appropriate interventions can be implemented to maintain adequate CPP and prevent further neurological damage. Documenting and continuing to monitor the parameters and checking the patient's pupillary response are important nursing actions but do not address the elevated ICP and low blood pressure. Elevating the head of the patient's bed may be appropriate if ordered by the physician, but it would not be the most appropriate action in this scenario without further assessment and intervention.

ICP Monitoring Is Instituted for a Patient with a Head