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NCTC MS unt 2 3rd s

Med surg unt 2 sem 3 NCTC

Acute: more life threatening, fast onset
Chronic: residual from CVA, alzheimer's, Parkinson's Guillian Barre Syndrome, may not see symptoms until really bad, we compensate, or patient will try to hide their lack. Watch for small changes they can be big.
Cranial Contents: 84% brain, blood 4% CSF 12%
 head injury compresses the brain - big changes quickly the pop off valve is the foramen magnum (big hole at the bottom of the skull) Brain stem - heart rate, respirations, LOC - no going back
Increased Intracranial Pressure - Causes tumor, head trauma, disease, aneurism, Will see LOC changes first confusion agitation lots of movement lethargic to stupor comatose
Glasgow Coma scale § 3-15 § 7 is comatose  □ Eye opening □ Speak □ Move independently □ response to pain
* Signs & Symptoms: of ICP ○ LOC ○ Headache § constant - doesn't go away § starts in the morning and gets worse with icp, relieves when head is elevated ○ Vomiting - especially without nausea is a neurological issue
Papilledema § optic nerve swollen □ vision change □ pupil response □ fixed and dilated □ unequal pupils □ check for prosthetic eyes if no pupillary response
○ VS for ICP § first pulse goes up § then goes down § systolic goes up § widening the pulse margin § Respirations slow § Cushing's triad
Cushing's triad □ heart rate up and down □ widen pulse pressure □ irregular respirations ® then chain stokes ◊ slow shallow uneven then apnea episodes
§ Posturing □ Decorticate - in to the core □ Decerebrate -
* Tests that determine underlying cause of IICP: ○ CT scan 10-15 min ○ MRI ○ Lumbar puncture ○ Intracranial pressure monitor ○ Do a good assessment -can tell how they are doing by a good neuro assessment
Created by: kcorkinsnctc
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