Mechanical ventilation with a rate and volume to maintain mild hyperventilation is used for a patient with head injury. To evaluate the effectiveness of this therapy, the nurse should:

Mechanical ventilation with a rate and volume to maintain mild hyperventilation is used for a patient with head injury. To evaluate the effectiveness of this therapy, the nurse should:

• A. Monitor oxygen saturation.
• B. Check arterial blood gases (ABGs).
• C. Monitor intracranial pressure (ICP).
• D. Assess patient breath sounds.

Answer: (C)

In head injury, mild hyperventilation lowers intracranial pressure by reducing PaCO2, which causes cerebral vasoconstriction and reduces cerebral blood volume. To know if this therapy is working, you need to see the brain’s pressure status directly—continuous ICP monitoring provides real-time data on whether ICP is decreasing toward safe levels. While arterial blood gases confirm that CO2 is in the target range and oxygen saturation shows oxygenation, neither alone reflects the brain’s actual pressure response. Breath sounds don’t inform intracranial dynamics. Therefore, tracking ICP is the best way to evaluate the effectiveness of this therapy.

In head injury, mild hyperventilation lowers intracranial pressure by reducing PaCO2, which causes cerebral vasoconstriction and reduces cerebral blood volume. To know if this therapy is working, you need to see the brain’s pressure status directly—continuous ICP monitoring provides real-time data on whether ICP is decreasing toward safe levels. While arterial blood gases confirm that CO2 is in the target range and oxygen saturation shows oxygenation, neither alone reflects the brain’s actual pressure response. Breath sounds don’t inform intracranial dynamics. Therefore, tracking ICP is the best way to evaluate the effectiveness of this therapy.