Neurological Question #7

Question

A nurse is caring for a client with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The client is on a ventilator and requires suctioning. Which of the following is a priority when suctioning a client with increased intracranial pressure?

Answers

  1. Suction as needed since the client requires airway clearance.
    • Rationale:
  2. Limit suction to every 30 minutes instead of every hour
    • Rationale:
  3. Limit the suction passes to reduce elevations in ICP.
    • Rationale:
  4. Limit suctioning because bradycardia may occur.
    • Rationale:

Overview

Explanation

Endotracheal suctioning with severe head injured clients may result in sudden increase in intracranial pressure and may increase the risk for further brain damage. Suction passes should be limited and should allow for rest periods between passes, should be hyperventilated, and provided increased oxygen prior to the procedure. Choices A and B would hasten the risk of increasing ICP and D is incorrect since bradycardia and ICP are not interrelated.

Learning Outcomes

Test Taking Tip

Video Rationale