On the intensive care unit, a patient with head trauma is on continuous mechanical ventilation. The patient develops increased intracranial pressure. Which among the following interventions should the nurse implement first?

Call the provider anticipating orders to hyperventilate the patient.


• Carbon dioxide has a potent vasodilating effect and this can increase cerebral blood flow, leading to higher ICP. Cerebral hypoxia may result if the high ICP puts too much pressure on the brain. The provider should be called to get orders to hyperventilate the patient. Hyperventilation is the first-line intervention to decrease ICP because it decreases carbon dioxide levels.

• Incorrect: Suctioning can stimulate coughing, leading to further hypoxia and increasing pressure via the Valsalva maneuver. If suctioning is required, hyperventilation is done prior to suctioning.

• Incorrect: Trendelenburg raises the feet higher than the head, increasing blood flow to the brain and raising ICP.

• Incorrect: High oxygen concentrations may decrease ICP, but too much oxygen can cause pulmonary fibrosis and seizures. Hyperventilation should be the first intervention.

Visit our website for other NCLEX topics now!