Page 1108 - Saunders Comprehensive Review For NCLEX-RN

signs of increased ICP occur.
6. Keep stimuli to a minimum; attempt to minimize
crying in an infant.
7. Withhold sedating medications during the acute phase
of the injury so that changes in levels of consciousness
can be assessed.
8. Initiate seizure precautions (Box 38-1).
9. Monitor for decreased responsiveness to pain (a
significant sign of altered level of consciousness).
10. Maintain NPO (nothing by mouth) status or provide
clear liquids, if prescribed, until it is determined that
vomiting will not occur.
11. Monitor prescribed intravenous fluids carefully to
avoid increasing any cerebral edema and to minimize
the possibility of overhydration.
12. Monitor for a fluid or electrolyte alteration (could
indicate injury to the hypothalamus or posterior
pituitary).
13. Assess wounds and dressings for the presence of
drainage, and monitor for nose or ear drainage, which
could indicate leakage of cerebrospinal fluid (CSF).
14. Administer tepid sponge baths or place the child on a
hypothermia blanket as prescribed if hyperthermia
occurs.
15. Avoid suctioning through the nares because of the
possibility of the catheter entering the brain through a
fracture, which places the child at high risk for a
secondary infection.
16. As prescribed, administer acetaminophen for
headache, anticonvulsants for seizures, and
antibiotics if a laceration is present; prepare to
administer prophylactic tetanus toxoid.
17. A corticosteroid or osmotic diuretic may be prescribed
to reduce cerebral edema.
18. Monitor for signs of brainstem involvement (Box 38-2).
19. Monitor for signs of epidural hematoma:
Asymmetrical pupils (one dilated, nonreactive pupil)
may indicate a neurosurgical emergency that requires
evacuation of the hematoma.

Drainage from the nose or ear needs to be tested for the

presence of glucose. Drainage that is positive for glucose (as tested
with reagent strips) indicates leakage of CSF. The PHCP must be
notified immediately if the drainage tests positive for glucose.
III. Hydrocephalus
A. Description
1. An imbalance of CSF absorption or production caused

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