— 生理適應 · HARD · SATA —
針對顱內壓（ICP）增高的患者，下列哪些護理措施是合適的？（選所有適合的）
Which of the following interventions is appropriate for a patient with increased intracranial pressure (ICP)? (Select all that apply.)
- AElevate the head of the bed to 30 degrees✓ 正解將床頭抬高 30 度
- BMaintain a quiet, dim environment✓ 正解保持安靜、昏暗的環境
- CCluster nursing care to minimize stimulation✓ 正解集中護理工作以減少刺激
- DEncourage coughing to clear secretions鼓勵咳嗽以清除分泌物
- EHyperventilate the patient continuously持續讓病人過度換氣
— Explanation · 中文詳解 —
顱內壓增高需控制腦血流與代謝。床頭抬高 30 度促進靜脈回流；減少感官刺激避免交感神經興奮。咳嗽會導致胸內壓增加，進而影響顱內靜脈回流，應避免。過度換氣僅在急性腦疝前期由醫師指示短暫執行，不可常規執行。
Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, while maintaining a quiet environment and clustering care minimize stimulation that could raise intracranial pressure. Coughing and routine hyperventilation are avoided because they increase intrathoracic pressure or cause cerebral ischemia, respectively. These interventions help control ICP by reducing metabolic demand and facilitating outflow.
✦ 台美臨床差異
兩地對於 ICP 監測與照護指引高度一致，但針對護理照顧集中化（Clustering）的實務細節可能因病房規範略有不同。