Health Promotion and Maintenance
86. A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child's ear level. What should be the nurse's priority action?
. Raise the drain to the child's ear level.
. Leave the drain as is and monitor the CSF drainage hourly.
. Quickly elevate the head of the bed.
. Clamp the drain and complete a neurological assessment.
Test-Taking Tip
Since tubes and drains work by pressure, the lower the drain, the less pressure required to induce drainage.
Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because simply raising the EVD to the proper level does not assess if the child is currently experiencing symptoms from improper EVD positioning. Answer 2 is incorrect because the EVD should not remain "as is" at a level below the ventricles. Answer 3 is incorrect because elevating the head of the bed will exacerbate the cerebrospinal fluid (CSF) drainage, since the EVD will become even lower than the level of the ventricles. Answer 4 is correct because the external ventricular drain (EVD) should be at the level of the ventricles, or at the child's ear level. When the EVD is too low, CSF can drain quickly and lead to neurologic complications. A nurse should prevent the CSF from draining any further and assess the child.