Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A. Give the client a warming blanket.
B. Administer low-dose barbiturate.
C. Encourage the client to hyperventilate.
D. Restrict fluids.
Correct Answer: C. Encourage the client to hyperventilate.
Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. Hyperventilation causes hypocapnia, which causes vasoconstriction, thus decreasing cerebral blood flow. Hyperventilation to moderate levels (PaCO2 = 25-35) is generally considered a short-term temporizing measure to decrease ICP. Extreme hyperventilation (PaCO2 <25mmHg) should be avoided (Levin et al., 2010).
Option A: A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload.
Option B: High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Blood pressure (BP) control when hypertension is severe (> 180/95 mm Hg). Mean arterial pressure needs to be high enough to maintain CPP even when ICP increases (Maiese, 2019). Hypotension should be promptly treated to avoid cerebral hypoperfusion.
Option D: Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg. Hydration with isotonic fluids. If there are no signs of dehydration or fluid overload, IV fluids with normal saline can be started at 50 to 75 mL/h. The rate can be adjusted based on serum sodium, osmolality, urine output, and physical assessment (Maiese, 2019).
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