A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Encourage the client to drink 3000 mL of fluid daily: The client has heart failure with a prescribed fluid restriction of 1000 mL/day. Encouraging excess fluid intake could worsen fluid overload and pulmonary edema, so this is not appropriate.

B. Use soap and water to provide perineal care: Proper perineal hygiene with soap and water reduces the risk of introducing bacteria into the urinary tract, helping prevent catheter-associated urinary tract infections (CAUTIs).

C. Place the drainage bag on the bed when transporting the client: The drainage bag should always be kept below the level of the bladder to prevent backflow and contamination. Placing it on the bed increases the risk of infection and is contraindicated.

D. Change the indwelling urinary catheter tubing every 3 days: Routine changing of the catheter tubing is not recommended as it can increase the risk of infection. Tubing should only be changed if it is compromised, soiled, or obstructed.

E. Empty the drainage bag when it is half-full: Regularly emptying the drainage bag before it becomes overly full prevents backflow and reduces bacterial proliferation, helping to decrease UTI risk.

F. Review the need for the indwelling urinary catheter daily: Assessing the ongoing need for the catheter allows for timely removal, which is the single most effective intervention to prevent catheter-associated urinary tract infections.

Rationale:

• Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
• Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.
• Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
• Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.