The pediatric nurse is caring for a child with increased intracranial pressure (ICP). The nurse places priority on completing which interventions? (Select all that apply.)

Question

A.
Administering mannitol (Osmitrol)
B.
Lowering the head of the bed
C.
Maintaining a patent airway
D.
Performing vigorous suctioning
E.
Preventing hyperthermia

Answer 1

ANS: A, C, E
Hyperthermia is to be avoided because brain metabolic needs will be greatly increased. The nurse may use a hypothermic blanket if the child's temperature is over 102 °F (39 °C). The head of the bed can be elevated 15 to 30 ° to promote venous blood return, but a side effect of elevating the head is that the pressure of blood being delivered to the brain decreases, resulting in inadequate blood supply and perfusion. A priority nursing intervention is maintenance of a patent airway. Inadequate oxygenation or excess carbon dioxide causes cerebral blood vessels to dilate, resulting in increased intracranial pressure (ICP). The nurse may administer medications to decrease cerebral edema. A drug frequently prescribed is mannitol (Osmitrol). The patient should be suctioned if needed, but suctioning can increased ICP and should be done gently and only when necessary.