Altered Loc And Increased Icp 1-16-07
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Altered Loc And Increased Icp 1-16-07 as PDF for free.
More details
- Words: 1,853
- Pages: 15
1-16-07
Faith Kennedy
Altered LOC •
A symptom of an underlying condition
•
The most important indicator or a neuro clients condition
•
Gauged on a continuum
•
Fully alert -------------------Coma
•
Terms used to describe altered LOC
•
o
Confusion-impaired decision making
o
Disorientation-to person, place, or time, or situation
o
Lethargic/drowsy-respond appropriately but very slowly, limited spontaneous movement, sluggish speech, will usually arouse to voice or light touch
o
Obtunded-arouse will stimulation, easily fall back asleep, may be disoriented when aroused
o
Stuporous-(considered unconscious) takes a lot of difficulty to arouse, very deep sleep, takes vigorous stimulation to arouse, may be combative, may be able to follow simple commands
o
Semi-comatose-responds only to painful stimuli, pull away from a painful stimuli-cross midline
o
Coma-unaware of self or environment, can last for day-years, no verbalization, no opening of eyes, no purposeful response to stimuli, hypotonic-lack muscle tone, posturing
o
Akinetic mutism-state of unresponsiveness to environment, no movement or sound but opens eyes
o
Persistent Vegetative state-permanent damage to cerebral cortex, patient is wakeful (eyes are open), but are void of any conscious content, might be able to swallow
Be sure to document your observations (don’t just check one of these terms on your charting)
Pathophysiology •
Causes:
•
o
Neurologic
o
Toxicologic-drugs or alcohol
o
Metabolic –renal failure, dka
Involves disruption in: o
Cells
o
Neurotransmitters
o
Structure/anatomy
Clinical manifestations •
Restlessness, anxiety
•
Slowing of verbal and motor responses
•
Pupillary changes-change depending on the cause o
Ex. drug overdose-pinpoint
o
Increased pressure on brain-dilated and sluggish
Assessment and Diagnostic Findings •
CT
•
MRI
•
PET
•
EEG
•
Laboratory Test
•
Thorough physical assessment
•
Glascow Coma Scale o
Measures eye opening, verbal and motor responses to stimuli
o
Scores from 3 (deep coma) to 15 (normal)
o
Children under 2 years old have different criteria than adults, because they can’t obey commands
o
7 or 8 is considered severe head injury/ coma
1-16-07
Faith Kennedy
Complications •
Respiratory failure
•
Pneumonia
•
Pressure ulcers
•
Aspiration
•
Contractures
•
Constipation
•
DVT
Medical management •
Obtain and maintain a patent airway
•
Monitor cardiac status
•
Nutrition and hydration
•
Determine and treat cause
•
Compensate for whatever they have lost
Nursing Assessment •
Assure the client is a t highest level of alertness
•
Have a parent present when assessing children
•
Verbal response
•
o
Orientation
o
Document if unable to assess (intubated)
Altertness o
•
Eye opening to command or stimulus
Motor response o
Purposeful, spontaneous, to stimulus
o
Posturing
o •
Decorticate
Decerebrate-indicates deeper brain damage, extension and external rotation
Flaccidity-worse than both, no response what so ever
Level of consciousness o
Response to stimuli
o
GCS
•
Pattern of respiration
•
Pupillary size and reaction
•
Eye movement (doll’s eyes)- only done by physician after spinal cord injury is ruled out, eyes should move together in the opposite direction the head is being moved
•
Oculovestibular response (Caloric test)-done by physician, eyes should deviate towards the stimulus
•
Protective reflexes o
Corneal
o
Gag
o
Loss of these two reflexes is a bad sign
•
Facial symmetry
•
Neck-meningitis
•
Deep tendon reflexes
•
Pathologic reflexes o
•
Babinski reflex- normal in babies up to 18 months-toes fan out, but if adult has positive babinski reflex this is abnormal
Abnormal posturing
Nursing Diagnosis •
Ineffective airway clearance
1-16-07
Faith Kennedy
•
R/F injury
•
Deficient fluid volume
•
Impaired oral mucous membranes
•
R/F impaired skin integrity
•
Impaired tissue integrity of cornea
•
Ineffective thermoregulation
Nursing Interventions •
Overall goal is to compensate for the client’s loss of protective reflexes
•
Maintaining the airways
•
•
•
o
Lateral or semi-prone positioning
o
Frequent mouth care and suctioning
o
HOB 30 degrees
o
Auscultate breath sounds q8h
o
May need intubation
Protecting the patient o
Side rails up X2, bed low
o
Avoid restraints if possible
o
Keep client calm and quiet
o
Protect client’s dignity
Maintaining nutrition and hydration o
I&O; daily weight
o
Slow IV fluid administration
o
NPO if unconscious
o
Tube feedings
Providing mouth care
•
•
•
•
•
o
Inspect for dryness, inflammation, crusting
o
Frequent oral care
o
Rotate ET tube site
Maintaining skin and joint integrity o
Frequent turning
o
Specialty beds
o
Passive ROM
o
Good body alignment
Preserving corneal integrity o
Clean with NS
o
Artificial tears
o
Close eyes before applying patch (need MD order)
Achieving thermoregulation o
Adjust environment
o
Administer antipyretics
o
Cool sponge baths, cooling blanket
Preventing urinary retention o
Assess for distention
o
Indwelling or intermittent catheterization
Promoting bowel function o o
•
Assess for abdominal distention Monitor bowel pattern
o
Check for impaction
o
Stool softeners, glycerin suppositories, enemas
Providing sensory stimulation
1-16-07
•
•
•
Faith Kennedy o
Maintain day/ night patterns
o
Touch and talk to client
o
Orient to time and place
o
Provide auditory stimulation
o
May need to decrease stimuli when client is arousing from coma
Meeting families needs o
Five accurate information
o
Provide emotional support
o
Refer to support groups
Monitoring and managing potential complications o
Respiratory failure
o
Pneumonia
o
Aspiration
o
Impaired skin integrity
o
DVT
Depending on cause o
Assess for seizures and increased ICP
o
Administer appropriate medications
Increased ICP •
“Box” theory-cranial vault is a large closed box that cannot expand o
85% is brain tissue
o
8% CSF
o
7% Blood
•
The body tries to compensate for changes, but has a very limited capacity
•
ICP-The force exerted by the brain, blood, and CSF within the skull
•
IF one component increases, then another must decrease (Monro-Kellie hypothesis)
•
Pressure remains in a state of equilibrium under normal conditions
•
Normal fluctuations do occur (sneezing, BP changes, O2 and CO2 levels)
•
Compensation is LIMITED!
•
Normal ICP : 10-20 mm Hg
Patho: increased ICP •
Relationship between intracranial volume and pressure is altered
•
Most commonly results from head trauma, but can also occur from tumor, hemorrhage, or infection
•
Results in : o
Decreased cerebral blood flow-compression of venous drainage system
o
Cerebral edema-fluid buildup in intra and extracellular spaces
o
Shifting of brain tissue-may rub up against rigid dural folds
o
Herniation
Cerebral Response to Increase ICP •
Pressure Autoregulation: o
•
Under normal circumstances, cerebral perfusion pressure (CPP) is maintained regardless of systemic blood pressure
Metabolic Autoregulation: o
Construction and dilation of blood vessels in response to O2 and CO2 levels
Compensation •
Most compensation for Increased ICP is accomplished through CSF regulation o
Decreased production
o
Increased reabsorption
o
Displacement
1-16-07 •
•
Faith Kennedy
The body compensates for increased ICP best when: o
There are small volume changes
o
The changes occur over longer periods of time
If compensation cannot be achieved, cerebral blood flow becomes compromised
Decompensation •
Autoregulatory mechanism fails
•
Venous compression and collapse with continued arterial flow to the brain, leading to increased ICP and decreased cerebral perfusion
•
Cerebral ischemia and infarction will occur
•
Herniation will occur and then brain death
Clinical manifestations of Increased ICP •
Altered LOC is the first sign
•
Motor and sensory loss
•
Headache
•
Pupillary changes- pupils begin to dilate (pressure on nerve III), sluggish
•
Papilledema-bulging of the optic disc- opthalmascope
•
Vomiting (projectile) due to pressure on medulla, sometimes no nausea
•
Alterations in Vital signs: o
•
Cushing’s response (Cushing’s reflex)
Elevated systolic BP
Widened pulse pressure
Slowing of heart rate
Bounding pulse
Altered respirations o
Initially increased
•
Elevated temperature
•
Cushing’s triad (decompensation)
•
o
Hypertension
o
Bradycardia
o
Bradypnea
Loss of brain stem reflexes (corneal/gag)
Lifespan Considerations •
Elderly o
•
May have increased ICP with delayed signs and symptoms due to cerebral atrophy (decreased brain mass)
Infants and Children o
May have increased ICP with delayed s/s due to open fontanels and sutures
o
Sutures may be re-opened up to the age of 10
Infants with Increased ICP •
Clinical Manifestations o
Tense, bulging fontanels
o
Separated cranial sutures
o
Macewen (cracked pot) sign-heard on percussion
o
Irritability
o
High-pitch cry
o
Increased head circumference
o
Distended scalp veins
o
Changes in feeding
o
Crying when held or rocked
o
“Setting sun” sign-eyes deviate downward
1-16-07
Faith Kennedy
Children with increased ICP •
Headache
•
Nausea
•
Vomiting (often without nausea)
•
Diplopia, blurred vision
•
Seizures
•
Personality and behavior changes
Diagnostic studies •
CT
•
MRI
•
PET
•
TCD
•
Lumbar Puncture is avoided- can cause brain stem herniation
Complications of Increased ICP •
Brain stem herniation
•
Diabetes insipidus
•
Syndrome of inappropriate antidiuretic hormone (SIADH)
Brain Herniation •
Shifting of brain tissue from an area of high pressure to an area of lower pressure through openings in rigid dura
Management of Increased ICP •
Treated as an EMERGENCY
•
Monitoring ICP o
Ventriculostomy- may see on floor, small catheter inserted into lateral ventricle, usually on non-dominant side of the brain 10-20 is normal ICP
•
•
o
Subarachnoid bolt
o
Epidural monitor
o
Fiberoptic monitor
Decreaseing cerebral edema o
Osmotic diuretics (mannitol)
o
Corticosteriods (dexamethasone)
o
Fluid restriction
Mantaining cerebral perfusion o
•
•
•
•
The only time we touch this is to change the drainage bag
Improving CPP by improving cardiac output (fluid volume, inotropic agents)
Reducing CSF and intracranial blood volume o
Cautious CSF drainage
o
Hyperventilation
Controlling fever o
Antipyretics
o
Cooling blanket
o
AVOID shivering (increases ICP)
Maintaining oxygenation o
ABG monitoring, O2 sat
o
O2 administration
Reducing metabolic demands o
High dose barbiturates
o
Pharmacologic paralytic agents
Nursing Diagnosis •
Ineffective airway clearance r/t diminished protective reflexes
1-16-07
Faith Kennedy
•
Ineffective breathing patterns r/t neurologic dysfunction
•
Ineffective cerebral tissue perfusion
Bowel/Bladder Dysfunction in the Neuro Client Goals of Management •
Control of incontinence
•
Establish regular elimination pattern
Etiology •
Neurological impairement
•
Cognitive impairement
•
Mobility/functional impairement-can’t get to the bathroom
Bladder dysfunction •
•
Assessment o
History
o
Baseline
Nursing Diagnosis o
Urinary retention
o
Incontinence
Reflex (neurogenic) •
Only reflexive emptying, can’t get conscious control
•
Upper neuron injury
•
Needs stimulation of reflex to empty
Functional •
Has conscious ability, but can’t
o
Total •
Don’t have conscious ability or functional ability to get to the bathroom
•
Goal is skin care
Self-care deficit: Toileting
Nursing Management: Bladder Dysfunction •
Bladder retraining o
Drink fluids 30 minutes before stimulating bladder reflex
•
Indwelling catheter insertion and care
•
Intermittent catheterization
•
Condom catheters
•
Increase fluids
•
Crede maneuver-increases abdominal pressure
•
Provide privacy
•
Barrier free access to toilet
•
Modification of clothing
•
Habit training
•
Management of incontinence
Bowel Dysfunction •
Assessment
•
Nursing Diagnosis o
Constipation
o
Diarrhea
o
Incontinence
Nursing management •
Bowel programs
1-16-07
Faith Kennedy
•
Digital stimulation
•
Barrier free access to toilet
•
Positioning
•
Dietary consideration
•
Increasing activity and exercise
•
Provide privacy
•
Medications
•
o
Bulk formers
o
Stool softeners
o
Mild laxative
o
Suppositories
Enemas
Faith Kennedy
Altered LOC •
A symptom of an underlying condition
•
The most important indicator or a neuro clients condition
•
Gauged on a continuum
•
Fully alert -------------------Coma
•
Terms used to describe altered LOC
•
o
Confusion-impaired decision making
o
Disorientation-to person, place, or time, or situation
o
Lethargic/drowsy-respond appropriately but very slowly, limited spontaneous movement, sluggish speech, will usually arouse to voice or light touch
o
Obtunded-arouse will stimulation, easily fall back asleep, may be disoriented when aroused
o
Stuporous-(considered unconscious) takes a lot of difficulty to arouse, very deep sleep, takes vigorous stimulation to arouse, may be combative, may be able to follow simple commands
o
Semi-comatose-responds only to painful stimuli, pull away from a painful stimuli-cross midline
o
Coma-unaware of self or environment, can last for day-years, no verbalization, no opening of eyes, no purposeful response to stimuli, hypotonic-lack muscle tone, posturing
o
Akinetic mutism-state of unresponsiveness to environment, no movement or sound but opens eyes
o
Persistent Vegetative state-permanent damage to cerebral cortex, patient is wakeful (eyes are open), but are void of any conscious content, might be able to swallow
Be sure to document your observations (don’t just check one of these terms on your charting)
Pathophysiology •
Causes:
•
o
Neurologic
o
Toxicologic-drugs or alcohol
o
Metabolic –renal failure, dka
Involves disruption in: o
Cells
o
Neurotransmitters
o
Structure/anatomy
Clinical manifestations •
Restlessness, anxiety
•
Slowing of verbal and motor responses
•
Pupillary changes-change depending on the cause o
Ex. drug overdose-pinpoint
o
Increased pressure on brain-dilated and sluggish
Assessment and Diagnostic Findings •
CT
•
MRI
•
PET
•
EEG
•
Laboratory Test
•
Thorough physical assessment
•
Glascow Coma Scale o
Measures eye opening, verbal and motor responses to stimuli
o
Scores from 3 (deep coma) to 15 (normal)
o
Children under 2 years old have different criteria than adults, because they can’t obey commands
o
7 or 8 is considered severe head injury/ coma
1-16-07
Faith Kennedy
Complications •
Respiratory failure
•
Pneumonia
•
Pressure ulcers
•
Aspiration
•
Contractures
•
Constipation
•
DVT
Medical management •
Obtain and maintain a patent airway
•
Monitor cardiac status
•
Nutrition and hydration
•
Determine and treat cause
•
Compensate for whatever they have lost
Nursing Assessment •
Assure the client is a t highest level of alertness
•
Have a parent present when assessing children
•
Verbal response
•
o
Orientation
o
Document if unable to assess (intubated)
Altertness o
•
Eye opening to command or stimulus
Motor response o
Purposeful, spontaneous, to stimulus
o
Posturing
o •
Decorticate
Decerebrate-indicates deeper brain damage, extension and external rotation
Flaccidity-worse than both, no response what so ever
Level of consciousness o
Response to stimuli
o
GCS
•
Pattern of respiration
•
Pupillary size and reaction
•
Eye movement (doll’s eyes)- only done by physician after spinal cord injury is ruled out, eyes should move together in the opposite direction the head is being moved
•
Oculovestibular response (Caloric test)-done by physician, eyes should deviate towards the stimulus
•
Protective reflexes o
Corneal
o
Gag
o
Loss of these two reflexes is a bad sign
•
Facial symmetry
•
Neck-meningitis
•
Deep tendon reflexes
•
Pathologic reflexes o
•
Babinski reflex- normal in babies up to 18 months-toes fan out, but if adult has positive babinski reflex this is abnormal
Abnormal posturing
Nursing Diagnosis •
Ineffective airway clearance
1-16-07
Faith Kennedy
•
R/F injury
•
Deficient fluid volume
•
Impaired oral mucous membranes
•
R/F impaired skin integrity
•
Impaired tissue integrity of cornea
•
Ineffective thermoregulation
Nursing Interventions •
Overall goal is to compensate for the client’s loss of protective reflexes
•
Maintaining the airways
•
•
•
o
Lateral or semi-prone positioning
o
Frequent mouth care and suctioning
o
HOB 30 degrees
o
Auscultate breath sounds q8h
o
May need intubation
Protecting the patient o
Side rails up X2, bed low
o
Avoid restraints if possible
o
Keep client calm and quiet
o
Protect client’s dignity
Maintaining nutrition and hydration o
I&O; daily weight
o
Slow IV fluid administration
o
NPO if unconscious
o
Tube feedings
Providing mouth care
•
•
•
•
•
o
Inspect for dryness, inflammation, crusting
o
Frequent oral care
o
Rotate ET tube site
Maintaining skin and joint integrity o
Frequent turning
o
Specialty beds
o
Passive ROM
o
Good body alignment
Preserving corneal integrity o
Clean with NS
o
Artificial tears
o
Close eyes before applying patch (need MD order)
Achieving thermoregulation o
Adjust environment
o
Administer antipyretics
o
Cool sponge baths, cooling blanket
Preventing urinary retention o
Assess for distention
o
Indwelling or intermittent catheterization
Promoting bowel function o o
•
Assess for abdominal distention Monitor bowel pattern
o
Check for impaction
o
Stool softeners, glycerin suppositories, enemas
Providing sensory stimulation
1-16-07
•
•
•
Faith Kennedy o
Maintain day/ night patterns
o
Touch and talk to client
o
Orient to time and place
o
Provide auditory stimulation
o
May need to decrease stimuli when client is arousing from coma
Meeting families needs o
Five accurate information
o
Provide emotional support
o
Refer to support groups
Monitoring and managing potential complications o
Respiratory failure
o
Pneumonia
o
Aspiration
o
Impaired skin integrity
o
DVT
Depending on cause o
Assess for seizures and increased ICP
o
Administer appropriate medications
Increased ICP •
“Box” theory-cranial vault is a large closed box that cannot expand o
85% is brain tissue
o
8% CSF
o
7% Blood
•
The body tries to compensate for changes, but has a very limited capacity
•
ICP-The force exerted by the brain, blood, and CSF within the skull
•
IF one component increases, then another must decrease (Monro-Kellie hypothesis)
•
Pressure remains in a state of equilibrium under normal conditions
•
Normal fluctuations do occur (sneezing, BP changes, O2 and CO2 levels)
•
Compensation is LIMITED!
•
Normal ICP : 10-20 mm Hg
Patho: increased ICP •
Relationship between intracranial volume and pressure is altered
•
Most commonly results from head trauma, but can also occur from tumor, hemorrhage, or infection
•
Results in : o
Decreased cerebral blood flow-compression of venous drainage system
o
Cerebral edema-fluid buildup in intra and extracellular spaces
o
Shifting of brain tissue-may rub up against rigid dural folds
o
Herniation
Cerebral Response to Increase ICP •
Pressure Autoregulation: o
•
Under normal circumstances, cerebral perfusion pressure (CPP) is maintained regardless of systemic blood pressure
Metabolic Autoregulation: o
Construction and dilation of blood vessels in response to O2 and CO2 levels
Compensation •
Most compensation for Increased ICP is accomplished through CSF regulation o
Decreased production
o
Increased reabsorption
o
Displacement
1-16-07 •
•
Faith Kennedy
The body compensates for increased ICP best when: o
There are small volume changes
o
The changes occur over longer periods of time
If compensation cannot be achieved, cerebral blood flow becomes compromised
Decompensation •
Autoregulatory mechanism fails
•
Venous compression and collapse with continued arterial flow to the brain, leading to increased ICP and decreased cerebral perfusion
•
Cerebral ischemia and infarction will occur
•
Herniation will occur and then brain death
Clinical manifestations of Increased ICP •
Altered LOC is the first sign
•
Motor and sensory loss
•
Headache
•
Pupillary changes- pupils begin to dilate (pressure on nerve III), sluggish
•
Papilledema-bulging of the optic disc- opthalmascope
•
Vomiting (projectile) due to pressure on medulla, sometimes no nausea
•
Alterations in Vital signs: o
•
Cushing’s response (Cushing’s reflex)
Elevated systolic BP
Widened pulse pressure
Slowing of heart rate
Bounding pulse
Altered respirations o
Initially increased
•
Elevated temperature
•
Cushing’s triad (decompensation)
•
o
Hypertension
o
Bradycardia
o
Bradypnea
Loss of brain stem reflexes (corneal/gag)
Lifespan Considerations •
Elderly o
•
May have increased ICP with delayed signs and symptoms due to cerebral atrophy (decreased brain mass)
Infants and Children o
May have increased ICP with delayed s/s due to open fontanels and sutures
o
Sutures may be re-opened up to the age of 10
Infants with Increased ICP •
Clinical Manifestations o
Tense, bulging fontanels
o
Separated cranial sutures
o
Macewen (cracked pot) sign-heard on percussion
o
Irritability
o
High-pitch cry
o
Increased head circumference
o
Distended scalp veins
o
Changes in feeding
o
Crying when held or rocked
o
“Setting sun” sign-eyes deviate downward
1-16-07
Faith Kennedy
Children with increased ICP •
Headache
•
Nausea
•
Vomiting (often without nausea)
•
Diplopia, blurred vision
•
Seizures
•
Personality and behavior changes
Diagnostic studies •
CT
•
MRI
•
PET
•
TCD
•
Lumbar Puncture is avoided- can cause brain stem herniation
Complications of Increased ICP •
Brain stem herniation
•
Diabetes insipidus
•
Syndrome of inappropriate antidiuretic hormone (SIADH)
Brain Herniation •
Shifting of brain tissue from an area of high pressure to an area of lower pressure through openings in rigid dura
Management of Increased ICP •
Treated as an EMERGENCY
•
Monitoring ICP o
Ventriculostomy- may see on floor, small catheter inserted into lateral ventricle, usually on non-dominant side of the brain 10-20 is normal ICP
•
•
o
Subarachnoid bolt
o
Epidural monitor
o
Fiberoptic monitor
Decreaseing cerebral edema o
Osmotic diuretics (mannitol)
o
Corticosteriods (dexamethasone)
o
Fluid restriction
Mantaining cerebral perfusion o
•
•
•
•
The only time we touch this is to change the drainage bag
Improving CPP by improving cardiac output (fluid volume, inotropic agents)
Reducing CSF and intracranial blood volume o
Cautious CSF drainage
o
Hyperventilation
Controlling fever o
Antipyretics
o
Cooling blanket
o
AVOID shivering (increases ICP)
Maintaining oxygenation o
ABG monitoring, O2 sat
o
O2 administration
Reducing metabolic demands o
High dose barbiturates
o
Pharmacologic paralytic agents
Nursing Diagnosis •
Ineffective airway clearance r/t diminished protective reflexes
1-16-07
Faith Kennedy
•
Ineffective breathing patterns r/t neurologic dysfunction
•
Ineffective cerebral tissue perfusion
Bowel/Bladder Dysfunction in the Neuro Client Goals of Management •
Control of incontinence
•
Establish regular elimination pattern
Etiology •
Neurological impairement
•
Cognitive impairement
•
Mobility/functional impairement-can’t get to the bathroom
Bladder dysfunction •
•
Assessment o
History
o
Baseline
Nursing Diagnosis o
Urinary retention
o
Incontinence
Reflex (neurogenic) •
Only reflexive emptying, can’t get conscious control
•
Upper neuron injury
•
Needs stimulation of reflex to empty
Functional •
Has conscious ability, but can’t
o
Total •
Don’t have conscious ability or functional ability to get to the bathroom
•
Goal is skin care
Self-care deficit: Toileting
Nursing Management: Bladder Dysfunction •
Bladder retraining o
Drink fluids 30 minutes before stimulating bladder reflex
•
Indwelling catheter insertion and care
•
Intermittent catheterization
•
Condom catheters
•
Increase fluids
•
Crede maneuver-increases abdominal pressure
•
Provide privacy
•
Barrier free access to toilet
•
Modification of clothing
•
Habit training
•
Management of incontinence
Bowel Dysfunction •
Assessment
•
Nursing Diagnosis o
Constipation
o
Diarrhea
o
Incontinence
Nursing management •
Bowel programs
1-16-07
Faith Kennedy
•
Digital stimulation
•
Barrier free access to toilet
•
Positioning
•
Dietary consideration
•
Increasing activity and exercise
•
Provide privacy
•
Medications
•
o
Bulk formers
o
Stool softeners
o
Mild laxative
o
Suppositories
Enemas
Related Documents
Altered Loc And Increased Icp 1-16-07
June 2020 1
Tca 1 (loc _ Icp)
June 2020 3
Icp
April 2020 5
Icp
October 2019 9
Loc And In A
June 2020 3