A 6-month-old infant with hydrocephalus is admitted to the hospital due to an enlarged head circumference, bulging fontanelles, and sunset eyes. What is the priority nursing responsibility?
Explanation
• Hydrocephalus can cause an increase in intracranial pressure (ICP).
• The nurse should monitor for signs of increasing ICP and assess for frontal bossing, dilated scalp veins, diplopia, vomiting, tense fontanelles, irritability, decreased level of consciousness, and changes in vital signs.
Incorrect answers:
• Increases in ICP can cause brain-stem compression, which can result in respiratory or cardiac failure. For this reason, while vital signs will be monitored, the ICP is the priority assessment because managing the ICP will control its effects on the vital signs.
• Measuring head circumference regularly is one indication of whether the condition is improving, but it is not the priority assessment.
• Promoting normal growth and development is not a priority during a severe acute illness.