A patient admitted for a head injury develops dry skin and a urine output of 400 ml/hr. Prioritize the nurse's next actions:
1. Notify the physician.
2. Complete a neuro assessment.
3. Assess the patient's urine specific gravity and blood sodium levels.
4. Start IV fluids and administer desmopressin (DDAVP).
• A urine output of 400 ml/hr after sustaining a head injury may be indicative of diabetes insipidus. Diabetes insipidus is the failure to produce an antidiuretic hormone due to damage to the pituitary gland from increased ICP. With a recent head injury, the nurse should first perform a neuro exam
• Notifying the physician is appropriate in order for the nurse to obtain orders for additional tests
• The nurse should then gather information by assessing for low specific gravity and elevated serum osmolarity, as ordered by the physician
• The physician may order treatments including IV fluids and DDAVP