ICP Signs and Symptoms
Intracranial Pressure (ICP) signs and symptoms:
– Confusion, disorientation, or agitation
– Loss of memory
– Any changes in vision, such as blurred vision or double vision
– Decreased LOC or difficulty arousing; extreme lethargy
– Numbness, tingling, or weakness in an arm or leg
– Persistent vomiting
– Speech problems
SIRES for allergic or anaphylactic reaction: Stabilize, Identify the toxin, Reverse the effect of toxin, Eliminate the toxin, and Support (respiration, circulation, and so forth).
Neurological assessment to identify LOC: AVPU
Alert – speaks and move spontaneously
Verbal – response to verbal stimuli only
Painful – response to painful stimuli only
Kussmaul breathing is a deep and gasp breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration.
Stertorous breathing is when air passes through secretions present in the air passages. These bubbling noises or rattles are characteristics before death, when the air passages are filled with mucus.
Cheyne stokes respirations are slow and shallow at first, gradually grow faster and deeper and then taper off until they stop entirely. Period of apnea may last for several seconds, and then the cycle is repeated. Usually the client experiencing cheyne stokes respiration is not cyanotic. Cheyne stokes respirations are serious and usually precede death in cerebral hemorrhage, uremia, or heart disease.
Arteriosclerosis is hardening of the walls, whereas arthrosclerosis is build up of plaque.
Eye Signs and assessment: PERRLA + C
PE – pupils equal
R – round
RL – react to light
A – accommodation ok
C – coordinated
Maceration is skin softening and breakdown due to moisture accumulation and lack of circulation.