Nurse's Pocket Guide

carina. Administer lidocaine intratracheally (reduces cough
reflex), hyperoxygenate before suctioning as appropriate to
minimize hypoxia.
• Maintain patency of urinary drainage system to reduce risk
of hypertension, increased ICP, and associated dysreflexia
when spinal cord injury is also present and spinal cord
shock is past. (Refer to ND Autonomic Dysreflexia.)
• Weigh, as indicated. Calculate fluid balance every shift/daily
to determine fluid needs/maintain hydration, prevent fluid
overload.
• Restrict fluid intake, as necessary, administer IV fluids via
pump/control device to prevent inadvertent fluid bolus or
vascular overload.
• Regulate environmental temperature; use cooling blanket as
indicated to decrease metabolic and O2 needs when fever
present or therapeutic hypothermia therapy is used.
• Investigate increased restlessness to determine causative factors
and initiate corrective measures as early as possible.
• Provide appropriate safety measures/initiate treatment for
seizures to prevent injury/increase of ICP/hypoxia.
• Administer supplemental oxygen, as indicated, to prevent
cerebral ischemia; hyperventilate (as indicated/per protocol)
when on mechanical ventilation.Therapeutic hyperventilation
may be used (PaCO2 of 30–35 mm) to reduce intracranial
hypertension for a short period of time, while other
methods of ICP control are initiated.
• Administer medications (e.g., antihypertensives, diuretics,
analgesics/sedatives, antipyretics, vasopressors, antiseizure
drugs, neuromuscular blocking agents, and corticosteroids),
as appropriate, to maintain cerebral homeostasis and manage
symptoms associated with neuological injury.
• Prepare client for surgery, as indicated (e.g., evacuation of
hematoma/space-occupying lesion), to reduce ICP/enhance
circulation.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/
Discharge Considerations):
• Discuss with caregivers specific situations (e.g., if client choking
or experiencing pain, needing to be repositioned, constipated,
blocked urinary flow) and review appropriate interventions to
prevent/limit episodic increases in ICP.
• Identify signs/symptoms suggesting increased ICP (in client
at risk without an ICP monitor); for example, restlessness,
deterioration in neurological responses. Review appropriate
interventions.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 429
decreased INTRACRANIAL ADAPTIVE CAPACITY