A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?
a. Document intracranial pressure every hour.
b. Turn and reposition the patient every 2 hours.
c. Check capillary blood glucose level every 6 hours.
d. Monitor cerebrospinal fluid color and volume hourly.
ANS: C
Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and in-tracranial pressure (ICP) require registered nurse (RN)–level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.
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