A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

Choice A: Tachypnea Tachypnea, or rapid breathing, is not typically a direct sign of increased ICP. While it can be associated with various medical conditions, it is not specifically indicative of increased ICP. However, it’s important to note that breathing patterns can change with advanced ICP changes, but these are usually characterized by irregularities rather than just increased rate. Increased intracranial pressure (ICP) is a critical condition that can occur after a traumatic brain injury (TBI). It results from the brain tissue’s response to injury, leading to swelling or bleeding within the skull. The skull is a rigid structure, so any increase in content, such as blood or edema, can lead to an increase in pressure.

Choice B: Hypotension Hypotension, or low blood pressure, is generally not associated with increased ICP. In fact, one of the signs of increased ICP is Cushing’s triad, which includes hypertension (high blood pressure), bradycardia (slow heart rate), and irregular respirations. Therefore, hypotension would not be a typical manifestation of increased ICP.

Choice C: Decreased level of consciousness A decreased level of consciousness is a hallmark sign of increased ICP. As pressure within the skull increases, it can lead to compression of the brain tissue and disruption of cerebral blood flow. This can manifest as changes in alertness, drowsiness, confusion, and in severe cases, loss of consciousness1. when monitoring a client who has sustained a TBI, the nurse should be vigilant for signs of increased ICP, with a decreased level of consciousness being a primary indicator. Other signs may include headache, nausea, vomiting, and changes in pupil size or reactivity. It is crucial to identify and treat increased ICP promptly to prevent further brain injury and potential long-term consequences.

Choice D: Bilateral weakness of extremities While bilateral weakness can be a sign of neurological damage, it is not specific to increased ICP. Increased ICP is more likely to cause global effects on consciousness and brain function rather than isolated weakness in limbs unless there is focal brain injury causing raised ICP.

Choice A reason:Lactulose is used in hepatic encephalopathy primarily to lower blood ammonia levels. It works by converting ammonia in the intestines into ammonium, which is then excreted³. Therefore, a decrease in ammonia levels would indicate the effectiveness of the medication.

Choice B reason:While lactulose can relieve constipation due to its laxative effect, relief of constipation is not the primary indicator of its effectiveness in treating hepatic encephalopathy³.

Choice C reason:Decreased liver enzymes are not a direct measure of lactulose's effectiveness in hepatic encephalopathy. Liver enzymes are indicators of liver function, not ammonia levels³.

Choice D reason:Relief of abdominal pain is not a specific indicator of lactulose's effectiveness in hepatic encephalopathy. The medication's primary role is to reduce ammonia levels, not to alleviate pain³.