Question

The nurse in the critical care unit is caring for a client with an ICP monitor in place. Assessment reveals a consistent ICP reading of 28 . Which action is appropriate? A. Lower the head of the bed B. Notify the physician C. Administer an extra dose of Decadron D. Document the finding

Short answer

Answer: Notify the physician.

Step-by-step solution

Understand the normal ICP range and the importance of an elevated ICP

The normal range for ICP in adults is 5-15 mmHg. An elevated ICP indicates increased pressure within the skull, which can potentially lead to serious complications like brain damage or death. If the ICP reading is consistently high, it usually requires urgent intervention.

Evaluate each option

A. Lower the head of the bed: This may temporarily help in reducing intracranial blood volume and reducing the ICP, but it may not be sufficient for a reading as high as 28. B. Notify the physician: Since the ICP is consistently elevated, it's important to notify the physician immediately for proper evaluation and management. This is usually the first step after discovering any abnormal finding. C. Administer an extra dose of Decadron: Decadron (dexamethasone) is a corticosteroid that has anti-inflammatory and immunosuppressive effects, and it may sometimes be used to help reduce ICP. However, administering extra doses without consulting a physician is not appropriate, as it may lead to complications or adverse effects. D. Document the finding: While documentation is essential, it's not enough as the only action in response to an elevated ICP. After taking appropriate action, as guided by a physician, documenting the findings and actions are important for proper patient management and communication among healthcare providers.

Identify the appropriate action

After analyzing the options, the most appropriate action is B. Notify the physician. This is because a consistent ICP reading of 28 is well above the normal range, and it's crucial to immediately inform the physician and follow their guidance for further management.

Key concepts

Critical Care Nursing

In critical care nursing, the role of the nurse is multi-faceted and crucial in ensuring patient safety and promoting optimal health outcomes. Caring for patients with potentially life-threatening conditions requires a high level of vigilance, in-depth knowledge, and swift decision-making.

Nurses in these settings utilize complex monitoring systems to observe vital signs, such as intracranial pressure (ICP), and need to act appropriately in response to critical changes. For instance, encountering an elevated ICP, as detailed in the exercise where the patient's ICP reading was 28 mmHg, requires immediate attention as this could indicate a severe threat to the patient's neurological status.

The nurse must be proficient in understanding the normal ranges of vital signs and recognizing deviations that warrant urgent intervention. Given the scenario, the correct step is to notify the physician immediately as this suggests that the patient may need rapid medical intervention to manage the raised ICP and prevent further complications.

Intracranial Pressure Management

Management of intracranial pressure (ICP) is a fundamental aspect of neurocritical care and involves a series of interventions to maintain ICP within normal ranges, specifically 5-15 mmHg for adults. Elevated ICP can be the result of a variety of conditions, including head trauma, brain hemorrhages, or tumors.

Strategies to manage increased ICP include medical, surgical, and nursing interventions. Medical interventions might encompass administration of osmotic diuretics or corticosteroids like Decadron. However, it is vital to understand that administration of any medication should only be done under a physician's guidance, as emphasized in the exercise solution.

Positioning the patient, such as elevating the head of the bed, can also influence ICP. Nonetheless, in cases of a significantly elevated ICP reading, relying solely on repositioning the patient is inadequate without further medical evaluation and intervention.

Neurological Assessment

Neurological assessment is an integral component of critical care nursing, particularly when monitoring patients with neurological complications or injuries. It includes evaluation of mental status, cranial nerve function, motor and sensory capabilities, reflexes, and ICP measurements.

When conducting a neurological assessment, it is essential for nurses to compare findings against standard benchmarks to determine normal or abnormal states. An elevated ICP reading, such as 28 mmHg, would be a significant deviation signaling potential neurological compromise, necessitating prompt action.

After identifying an abnormal finding, nurses must use clinical judgment and adhere to established protocols, such as immediately notifying the physician for a potentially life-threatening issue. This ensures that the appropriate medical team can make timely decisions for further management and treatment, as was the correct course of action in the provided textbook solution.