— 生理適應 · HARD · SATA —
針對腦內壓（ICP）升高的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following nursing interventions are appropriate for a client 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
- BHyperventilate the client to keep PaCO2 low對病人進行過度換氣以維持低PaCO2
- CCluster nursing activities to minimize stimulation集中護理活動以最小化刺激
- DMaintain the neck in a midline neutral position✓ 正解保持頸部在中線中立位置
- EAdminister stool softeners to prevent straining✓ 正解給予糞便軟化劑以防止用力排便
— Explanation · 中文詳解 —
腦內壓（ICP）升高的照護重點在於促進腦靜脈回流及避免腹內壓升高。1.抬高頭部（30度）以利靜脈回流；2.頸部維持中立位，避免壓迫頸靜脈導致 ICP 升高；3.預防便秘與努責（straining）以避免腹內壓升高導致 ICP 波動。過度換氣已非例行常規。集中照護活動應適度，避免過於頻繁的刺激導致 ICP 波動。
Elevating the head of the bed to 30 degrees and maintaining a neutral neck position promote venous drainage from the brain, thereby reducing intracranial pressure. Administering stool softeners prevents straining, which avoids the Valsalva maneuver and subsequent spikes in ICP, while prophylactic hyperventilation is no longer recommended as a routine intervention.