Question

A client is in the intensive care unit following a motor vehicle accident with a sustained head injury. Intracranial pressure monitor (ICP) is in place with a reading of 32 . Arterial line shows a mean arterial pressure (MAP) of 80 . Which nursing action is appropriate? A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48 B. Document these results on the client record in the nurse's notes C. Turn the client on her side with her knees bent upward in preparation for a lumbar puncture D. Notify the doctor that the client has a CPP of 112

Short answer

Answer: A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48.

Step-by-step solution

Calculate CPP using the provided formula

To calculate the CPP, we can use the formula CPP=MAP-ICP. We plug in the given values of ICP (32) and MAP (80) to obtain the CPP. CPP = 80 - 32 CPP = 48 The calculated CPP is 48.

Determine the appropriate nursing action based on the calculated CPP

With the CPP calculated as 48, we can now determine the appropriate nursing action among the provided options: A. Notify the physician that the client has a cerebral perfusion pressure (CPP) of 48 B. Document these results on the client record in the nurse's notes C. Turn the client on her side with her knees bent upward in preparation for a lumbar puncture D. Notify the doctor that the client has a CPP of 112 Option A is the correct answer, as it correctly identifies the calculated CPP and requests to notify the physician about the client's condition. The other options either inaccurately identify the CPP or involve actions that may not be necessary or appropriate based on the calculated CPP value.