— 生理適應 · MEDIUM · MCQ —
對於顱內壓（ICP）升高的病人，下列何項護理措施為優先？
Which of the following nursing interventions is priority for a client with increased intracranial pressure (ICP)?
- AMaintain the head of bed at 30 degrees✓ 正解將床頭抬高 30 度
- BEncourage frequent coughing to clear secretions鼓勵頻繁咳嗽以清除分泌物
- CPerform passive range-of-motion exercises every hour每小時進行被動關節活動運動
- DPerform aggressive chest physiotherapy進行強烈的胸部物理治療
— Explanation · 中文詳解 —
顱內壓（Intracranial Pressure, ICP）升高時，護理的核心原則是「維持腦灌流壓（Cerebral Perfusion Pressure, CPP）」。維持頭部抬高 30 度角（Head of Bed, HOB 30°）是促進顱內靜脈回流、減少腦充血最簡單且有效的物理方法。任何增加胸內壓或腹內壓的動作（如咳嗽、用力）都會阻礙靜脈回流，進而加劇 ICP 升高。
Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, thereby reducing intracranial pressure and maintaining cerebral perfusion. Activities that increase intrathoracic pressure, such as coughing or aggressive chest physiotherapy, can impede venous return and worsen intracranial hypertension.
✦ 台美臨床差異
美國臨床對於 ICP 高的病人，通常會嚴格執行『避免刺激性護理』，包括限制探訪與減低環境光線噪音，這在 NCLEX 考試中常被視為與 HOB 30° 同樣重要的護理方針。