— 生理適應 · HARD · SATA —
下列哪些護理措施有助於降低顱內壓（ICP）？（選所有適合的）
Which of the following nursing actions help decrease intracranial pressure (ICP)? (Select all that apply.)
- AMaintain the head of the bed at 30 degrees✓ 正解將床頭抬高30度
- BKeep the neck in a neutral alignment✓ 正解保持頸部中立對位
- CAdminister stool softeners to prevent straining✓ 正解給予糞便軟化劑以防止用力排便
- DPerform vigorous physical therapy exercises執行劇烈的物理治療運動
- ELimit suctioning to brief durations✓ 正解限制抽吸時間為短促
— Explanation · 中文詳解 —
降低顱內壓的關鍵在於促進靜脈回流與減少刺激。抬高床頭 30 度、頭頸維持中線可優化回流；預防便秘可避免 Valsalva 動作造成壓力升高；抽吸需限制時間以防缺氧與血壓波動；激烈運動會增加腹壓與顱內壓，應避免。
To decrease intracranial pressure, the nurse should maintain the head of the bed at 30 degrees and keep the neck in neutral alignment to promote venous drainage. Additionally, administering stool softeners prevents straining, and limiting suctioning duration avoids hypoxemia, both of which can elevate ICP.
✦ 台美臨床差異
兩地在 ICP 的照護重點一致，但美國醫院內對於這類病人常設有 ICP 的持續監測 alarm 閾值 protocol。