This causes pupillary dilation on the side of the pressure. An obstruction of the shunt can lead to increased intracranial pressure (ICP). Manifestations of infection include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. Infection is the greatest hazard in the postoperative period. Which assessment does the nurse recognize as a sign of infection of the cerebrospinal fluid? The nurse is providing postoperative care for a child with hydrocephalus. Pain medication should not be given because it can often mask the signs of increasing ICP. The nurse is noting signs of increased ICP therefore this assessment has already been completed. Determination of the level of consciousness should be done as part of the assessment. The practitioner should be notified immediately because this is considered a medical emergency. The worsening of symptoms may indicate that the intracranial pressure (ICP) is increasing. Observing the child closely for signs of increased intracranial pressure 1 What is the most appropriate nursing action?Īssessing the child for level of consciousnessĪdministering pain medication and assessing the response During an assessment the nurse notes that the child is becoming irritable and the pupils are unequal and sluggish. The nurse is caring for a toddler who has undergone surgery for a brain tumor.
Brain damage is not a common complication of VP shunt insertion. Leakage and malfunction are common complications after VP shunt insertion but not the most common. Infection is the most serious complication of placement of a ventriculoperitoneal (VP) shunt to correct hydrocephalus. What is the most serious complication of placement of a ventriculoperitoneal shunt used to correct hydrocephalus? The patient is asked to report nasal bleeding, but priority is given to check for CSF leakage. Sedating by administering an antihistamine is not appropriate in managing rhinorrhea of head injury.
Reassurance is given only after excluding CSF leakage. The watery nasal discharge is tested for presence of glucose to rule out cerebrospinal fluid (CSF) leakage. Patients with head injury may have leakage of cerebrospinal fluids. Sedate the patient and administer antihistamine.Īsk the patient to report immediately if the nose bleeds. Test the discharge for presence of glucose. Reassure the patient, because it is an insignificant finding. What immediate nursing intervention is appropriate for the patient? A patient who has sustained a head injury exhibits rhinorrhea. Its absence does not suggest dysfunction of the parietal lobe, frontal cortex, or temporal lobe. What does the absence of the doll's-head maneuver indicate?Ībsence of the doll's head maneuver suggests dysfunction of the brainstem or oculomotor nerve (cranial nerve III). The nurse assesses a child for the doll's-head maneuver.
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