Page 2017 - Saunders Comprehensive Review For NCLEX-RN

when tested using a strip test.

3. Interventions

a. Monitor respiratory status and maintain
a patent airway, because increased
carbon dioxide (CO ) levels increase
2
cerebral edema.
b. Monitor neurological status and vital
signs, including temperature.
c. Monitor for increased ICP.
d. Maintain head elevation to reduce
venous pressure.
e. Prevent neck flexion.
f. Initiate normothermia measures for
increased temperature.
g. Assess cranial nerve function, reflexes,
and motor and sensory function.
h. Initiate seizure precautions.
i. Monitor for pain and restlessness.
j. Morphine sulfate or opioid medication
may be prescribed to decrease
agitation and control restlessness
caused by pain for the head-injured
client on a ventilator; administer with
caution because it is a respiratory
depressant and may increase ICP.
k. Monitor for drainage from the nose or
ears, because this fluid may be CSF.

l. Do not attempt to clean the nose,

suction, or allow the client to blow her
or his nose if drainage occurs.

m. Do not clean the ear if drainage

is noted, but apply a loose, dry sterile
dressing.

n. Check drainage for the presence

of CSF.

o. Notify the PHCP if drainage

from the ears or nose is noted and if
the drainage tests positive for CSF.
p. Instruct the client to avoid coughing
because this increases ICP.
q. Monitor for signs of infection.

2017