A 6-year-old child with bacterial meningitis is receiving IV antibiotics and has been experiencing increased intracranial pressure (ICP). The child's Glasgow Coma Scale score has decreased from 12 to 8 over the past 2 hours. Which nursing intervention should be the priority?

A drop in Glasgow Coma Scale (GCS) to 8 or below in a child with bacterial meningitis is a critical event signaling impending respiratory failure and brainstem herniation. The airway is the immediate priority. The nurse must activate the emergency response system, notify the provider, and prepare for rapid sequence intubation. Controlled ventilation after intubation allows for mild hyperventilation to temporarily reduce ICP while definitive treatments take effect.

• Keep head of bed elevated to 30 degrees (avoid 45 degrees to prevent jugular vein compression) and maintain neutral neck alignment to promote cerebral venous outflow.
• Avoid clustering care activities that can spike ICP, such as suctioning, unless absolutely necessary; pre-oxygenate with 100% oxygen before suctioning.
• Maintain normothermia with antipyretics as prescribed, as fever increases cerebral metabolic rate and oxygen consumption.
• Ensure all emergency airway equipment, including suction, bag-valve-mask, and endotracheal tubes, is at the bedside and functional.

Once the airway is secured, continuous monitoring of end-tidal CO2 is essential to maintain PaCO2 in the low-normal range (35-38 mmHg), avoiding aggressive hyperventilation that can cause cerebral ischemia. Neurological assessments, including pupil reactivity and motor responses, should continue every 15 minutes to detect further deterioration. Strict fluid management and administration of osmotic diuretics like mannitol may be ordered to control ICP.