The nurse assessing the 4-month-old brought to the emergency room for poor feeding and signs of dehydration notes the infant seems to be looking down and sclera is visible superior to the iris. The nurse reports this assessment to the provider and receives orders for care. Which order does the nurse question?

Prepare patient for lumbar puncture to obtain cerebrospinal fluid. A lumbar puncture is contraindicated in the patient with increased intracranial pressure, which should be suspected in the patient with poor feeding and sunsetting eyes (sclera visible superior to the iris). An MRI should occur prior to the LP. Frequent neurologic assessments with vital signs should be performed to detect deterioration in the patient. Blood and urine cultures are appropriate because meningitis may have caused the increased ICP.

The nurse assessing the 4-month-old brought to the emergency room...

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Reduction of Risk Potential
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Category: Reduction of Risk Potential
Difficulty: 9

Topics: Assessment Communication & Documentation Neurology HEENT Infection Inflammation Laboratory Studies

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