Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 17-5

Caring for a Patient with an External Ventriculostomy

(Intraventricular Catheter–Closed

Fluid-Filled System)

Goal:The patient maintains intracranial pressure at less than

10 to 15 mm Hg, and cerebral perfusion pressure at

60 to 90 mm Hg. Comments

1. Review the medical orders for specific information about
   ventriculostomy parameters.


2. Gather the necessary supplies and bring to the bedside
   stand or overbed table.


3. Perform hand hygiene and put on PPE, if indicated.


4. Identify the patient.


5. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient.


6. Assess patient for any changes in neurologic status. (See
   Chapter 2, Health Assessment, for details of assessment.)
   7.Assess the height of the ventriculostomy system to ensure
   that the stopcock is at the level of midpoint between the
   outer canthus of the patient’s eye and the tragus of the
   patient’s ear or external auditory canal (Littlejohns, 2005),
   using carpenter level, bubble-line level, or laser level,
   according to facility policy.Adjust the height of the system
   if needed. Move the drip chamber to the ordered height.
   Assess the amount of CSF in the drip chamber if the
   ventriculostomy is draining.
   8.Zero the transducer.Turn stopcock off to the patient.
   Remove the cap from the transducer, being careful not to
   touch the end of the cap. Press and hold the calibration
   button on the monitor until the monitor beeps. Return the
   cap to the transducer. Turn the stopcock off to the drip
   chamber to obtain an ICP reading. After obtaining a
   reading, turn the stopcock off to the transducer.
   9.Adjust the ventriculostomy height to prevent too much
   drainage, too little drainage, or inaccurate ICP readings.

ExcellentSatisfactoryNeeds Practice