— 生理適應 · HARD · SATA —
護理師監測一位顱內壓 (ICP) 為 22 mmHg 的病患。應執行哪些措施？（選所有適合的）
A nurse is monitoring a client with an intracranial pressure (ICP) of 22 mmHg. Which interventions should the nurse implement? (Select all that apply.)
- AKeep the head of the bed elevated at 30 degrees✓ 正解將床頭抬高30度
- BCluster all nursing care to minimize stimulation集中護理活動以減少刺激
- CMaintain the head in a neutral position✓ 正解維持頭部中立位置
- DAdminister stool softeners to prevent straining✓ 正解給予軟便劑以防止用力排便
- EHyperventilate the client for long-term management對病人進行過度換氣以進行長期管理
— Explanation · 中文詳解 —
ICP > 20 mmHg 為危險指標。抬高床頭（30度）助靜脈回流；中立位防止頸靜脈受壓；預防便秘與用力（Valsalva maneuver）以防腹壓升高導致 ICP 飆升。過度集中護理可能導致壓力累積（需適度間隔）；過度換氣僅在急救短期使用。
Elevating the head of the bed to 30 degrees and maintaining a neutral head position promote venous drainage from the brain, helping to reduce intracranial pressure. Administering stool softeners prevents straining, which can increase intrathoracic and intracranial pressure through the Valsalva maneuver.
✦ 台美臨床差異
美國醫院強調「ICP bundle care」；台灣醫院則對 ICP 監測器材使用較為嚴格，通常僅在加護病房由專科護理師執行。