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The highest priority in managing patients with SDH is to maintain a patent airway, appropriate ventilation and oxygenation, and adequate circulation. Make sure the patient's endotracheal tube is anchored well. If the patient is at risk for self-extubation, maintain him or her in soft restraints. Note the lip level of the endotracheal tube to determine if tube movement occurs. Notify the physician if the patient's PaO2 drops below 80 mm Hg, PaCO2 exceeds 40 mm Hg, or severe hypocapnia (PaCO2 <25 mm Hg) occurs.

Help control the patient's ICP. Maintain normothermia by avoiding body temperature elevations. Avoid flexing, extending, or rotating the patient's neck because these maneuvers limit venous drainage of the brain and thus raise ICP. Avoid hip flexion by maintaining the patient in a normal body alignment, thus limiting venous drainage. Maintain a quiet, restful environment with minimal stimulation; limit visitors as appropriate. Time nursing care activities carefully to limit prolonged ICP elevations. Use caution when suctioning the patient: hyperventilate the patient beforehand, and suction only as long as necessary. When turning the patient, prevent Valsalva's maneuver by using a draw sheet to pull the patient up in bed. Instruct the patient not to hold on to the side rails.

Strategies to maximize the coping mechanisms of the patient and family are directed toward providing support and encouragement. Provide simple educational tools about head injuries. Teach the patient and family appropriate rehabilitative exercises, as necessary. Help the patient cope with long stretches of immobility by providing diversionary activities appropriate to the patient's mental and physical abilities. Head injury support groups may be helpful. Referrals to clinical nurse specialists, pastoral care staff, and social workers are helpful in developing strategies for support and education.

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