1. Explain the physiological mechanism that maintains normal intracranial pressure.

 The brain is a rigid box containing brain tissue – 1400 g, blood – 75 mL, and CSF – 75 mL that can’t readily
accommodate increasing volumes because it can’t expand. It has similar properties to a suitcase; its size is
fixed and it contains an assortment of necessary things but there is a limit as to what it can put in it. The skill
has three essential components which are brain tissue with 78%, blood 12%, and cerebrospinal fluid 10%.
The normal supine intracranial pressure is 10-15 mmHg, measured at a position equal to the level of the
foramen of Monro. The intracranial pressure is directly related to the volume of the intracranial contents
within the skull. The Monro-Kellie Doctrine is the cranial is a rigid sphere filled to capacity with no
compressible contents and that an increase in the volume of one of the constituents will lead to a rise in
intracranial pressure. Intracranial is equal to the CSF pressure, the pressure that must be exerted against a
needle introduced into the CSF space to just prevent escape of fluid. Brain is one of the largest organ in the
head where it composed of 1300 – 1750 mL: Tissue with has 300-400 mL, intra- cellular fluid with 900 –
1000 mL, and extra – cellular fluid 100 – 150 mL. The blood is in the brain also composed of 100 – 150 mL
and cerebral spinal fluid 100 – 150 mL.
 The cranium is a fixed box containing brain tissue, blood and cerebrospinal fluid that cannot readily
accommodate increasing volumes because it cannot expand. The average volume of the adult cranium is
about 1,900 mL, about 80% of which is occupied by the brain. There are three major divisions of the brain:
the cerebrum, cerebellum and brain stem. The cerebrum is divided into two lobes, and each is responsible
for specific “higher functions,” such as consciousness and thought. The cerebellum is responsible for
balance and fine-tuned movements. The brain stem is made up of the diencephalon, midbrain and medulla
oblongata. The medulla oblongata connects the brain with the spinal cord and is responsible for control of
cardiovascular and respiratory function. Normal intracranial pressure is 10-15 mmHg, this is accomplished
by shunting CSF(to lumbar subarachnoid space), returning venous blood to the heart, and if necessary,
shifting away from the site of edema inside the skull. It would be like packing the extra stud into a second
suitcase. These compensatory mechanisms function to maintain the steady relationship of volume to
pressure inside the skull. Cerebrospinal fluid secreted at the rate of 500 mL per day. Secreted by the
choroid plexus in the lateral ventricles. Increased intracranial pressure is defined as a sustained elevation in
pressure above 20 mm of Hg. During slow increase in volume in a continuous mode, the ICP rises to a
plateau level at which the increase level of CSF absorption keeps pace with the increase in volume.
Intermittent expansion causes only a transient rise in ICP at first. When sufficient CSF has been absorbed to
accommodate the volume the ICP returns to normal. Expansion to a critical volume does however cause
persistent rise in ICP which thereafter increases logarithmically with increasing volume.

2. Describe the common etiologies, clinical manifestations and collaborative care of the patient with increased
intracranial pressure.
 There are several conditions where it can contribute to increase in intracranial pressure. First is the increase
of the brain volume such as: intracranial mass like tumor, hematoma, aneurysm, and arteriovenous
malformation. Cerebral edema and central nervous system infection like abscess, inflammatory process.
Secondly, an increased in blood volume like obstruction of venous outflow, hyperemia, hypercapnia. Finally,
an increased in CSF volume like the overproduction of CSF, decreased reabsorption of CSF with the cause
meningitis and subarachnoid hemorrhage, and obstruction to flow of cerebral spinal fluid.
  The increased in the brain volume is categorized in different types includes: intracranial space occupying
lesions, brain tumors, brain abscess, intracranial hematoma, intracranial vascular malformation, cerebral
edema, encephalitis, meningitis, hypoxic ischemic encephalopathy, traumatic brain injury, hepatic
encephalopathy, Reye’s syndrome, and stroke. Increase in the CSF volume includes: hydrocephalous and
choroids plexus papilloma. Increased blood volume includes: vascular malformations, cerebral venous
thrombosis, meningitis, and encephalitis. Brain hemorrhage - blood leaking from a blood vessel, blood
rupture and localized bleeding. Ischemia stroke – blood vessel that supplies blood to the brain is blocked by
blood clots which categorized into two thrombotic stroke and embolic stroke. Brain injury – traumatic injury
like concussion, contusion and lacerations.
 When ICP increases to the point at which the brain’s ability to adjust has reached its limits, neural function is
impaired; this may be manifested by clinical changes first in LOC and later by abnormal respiratory and
vasomotor responses. Slowing of speech and delay in response to verbal suggestions are other early
indications. Restlessness, confusion, or increasing drowsiness, has neurologic significance. These signs
may result from compression of the brain due to swelling from hemorrhage or edema, an expanding
intracranial lesion or a combination of both hematoma and tumor. As ICP increases, the patient becomes
stuporous, reacting only to loud auditory or painful stimuli. At this stage, serious impairment of brain
circulation is probably taking place, and immediate intervention is required.
 Collaborative care was varies but the primary goal for patient with increased intracranial pressure include:
adequate oxygenation to determine whether patient require mechanical ventilator. If the patient is not
ventilating effectively, initiate BVM ventilation with 100% oxygen. For patients showing signs of herniation
(posturing, fixed and dilated pupil, erratic respirations), hyperventilation can be considered as a short-term
bridging treatment until ICP can be relieved. Drug therapy such as mannitol, loop diuretics, barbiturates,
anti-seizure drug and corticosteroids. Diuretics increase the osmolarity of the blood, causing more fluid to be
pulled from tissues (specifically the brain) into the intravascular space. Once it’s there, the body can then
eliminate the excess fluid. The needs for nutritional therapy such as increasing the need for glucose and
keeping patient blood volume normal in the body by administering intravenous fluid with a content of 0.45%
or 0.9% sodium chloride. And finally, Hyperventilation therapy briefly used for refractory intracranial
hypertension to increase the risk for focal cerebral ischemia. The basis for hyperventilation in the treatment
of increased ICP is the normal physiologic response of the cerebral vasculature to pCO2. As
pCO2 decreases with hyperventilation, cerebral vasoconstriction occurs, and the volume of blood within the
cranial vault deceases.

3. Describe the collaborative and nursing management care of the patient with increased intracranial pressure.
 Collaborative care was varies but the primary goal for patient with increased intracranial pressure include:
adequate oxygenation to determine whether patient require mechanical ventilator. If the patient is not
ventilating effectively, initiate BVM ventilation with 100% oxygen. For patients showing signs of herniation
(posturing, fixed and dilated pupil, erratic respirations), hyperventilation can be considered as a short-term
bridging treatment until ICP can be relieved. Drug therapy such as mannitol, loop diuretics, barbiturates,
anti-seizure drug and corticosteroids. Diuretics increase the osmolarity of the blood, causing more fluid to be
pulled from tissues (specifically the brain) into the intravascular space. Once it’s there, the body can then
eliminate the excess fluid. The needs for nutritional therapy such as increasing the need for glucose and
keeping patient blood volume normal in the body by administering intravenous fluid with a content of 0.45%
or 0.9% sodium chloride. And finally, Hyperventilation therapy briefly used for refractory intracranial
hypertension to increase the risk for focal cerebral ischemia. The basis for hyperventilation in the treatment
of increased ICP is the normal physiologic response of the cerebral vasculature to pCO2. As
 pCO2 decreases with hyperventilation, cerebral vasoconstriction occurs, and the volume of blood within the
cranial vault deceases.
 Nursing management in patient with increased intracranial pressure includes: First an assessment to
determine consciousness with the use of GCS and neurologic assessment, Obtain a history of events
leading the present illness; it may be necessary to obtain this information form significant others. The
neurologic examination should include an evaluation of mental status. Level of consciousness, cranial nerve
function, cerebellar function, reflexes, and motor and sensory function. Assessment of LOC includes eye
opening; verbal and motor responses and pupils size, equality, reactions to light. Secondly, getting the basic
assessment of the patient with is the vital signs like BP, pulse, RR, Temperature and its SPO2, also, the
needs to determine the motor strength and response of the patient. Finally the needs for maintaining patient
airway suction with care the secretions obstructing the airway because transient elevations of ICP occur
with suctioning. The patient should maintain hyper-oxygenated before and after suctioning to maintain
adequate oxygenation. The needs for discouraging the coughing because it increases intracranial pressure.
Auscultate the lungs fields at least every 8 hours to determine the presence of abnormal breath sounds..
Furthermore, maintain head alignment and elevate head of bed 30 degrees. The rationale is that
hyperextension, rotation, or hyperflexion of the neck causes decreased venous return. Avoid extreme hip
flexion as this increases intra- abdominal and intra- thoracic pressures, leading to rise in ICP. And when
moving or being turned in bed, instruct the patient to exhale to avoid the Valsalva maneuver. Patient with
the potential for a significant increase in ICP should receive sedation or paralyzation before initiation of
many nursing activities.

4. Differentiate types of head injury by mechanism of injury and clinical manifestations.

 Its clinical manifestation that can possibly occur includes – headache that often continuous and worsen in
the morning, nausea or vomiting, a change in level of consciousness, change in the vital signs (cushing
triad), ocular signs – pupils won’t dilate, the decrease in motor function maybe decerebrate posturing or
decorticate posturing.
 The types of head injury are: Concussion a temporary loss of neurological function with no apparent
structural damage. Contusion is a moderate to severe head injury, bruise and an impact of the brain against
the skull. Head injury also categorize in to different types which are: Diffuse axonal injury damage in the
axons of the white matter of the cerebral hemispheres, basal ganglia, thalamus, and brainstem which cause
decreased LOC, increased ICP, decerebration or decortication, edema. Epidural hematoma – bleeding
between the dura and the inner surface of the skill which cause Initial period of unconsciousness, brief lucid
interval followed by decrease in LOC, headache, nausea, vomiting, and focal findings. Subdural hematoma
– bleeding between the dura mater and arachnoid layer of the brain cause drowsy, confusedness, and
dilates on the side of the bleed and stays dilated
 Open head injury - open head injuries occur when the skill has been broken and the brain exposed. This
may damage the brain tissue immediately below the fracture causing loss of consciousness as well as more
generalized damage as in a closed head injury. Closed head injury - closed head injury occurs when the
head is struck but the skull is not penetrated or fractured. Even so someone can lose consciousness and
the brain can be seriously damage. Post concessional syndrome – symptoms such as headache dizziness
deafness, ringing in the ears, memory impairment and short attention span may occur after minor head
injury. These symptoms vary from person to person but are labelled post concessional syndrome.
Explanation and advice should be sought from your local doctor who may refer you to a neurologist. And
minor head injury - a minor head injury may occur if the head is moved violently or struck. Hospitalization
may not be necessary and sometimes there is no loss of consciousness. Even so, some people experience
behavioral and cognitive problems, which can interfere with their lives as a result. It is important to get
information to understand the possible effects this may have on you
  Clinical manifestation depend upon the degree and level spinal cord injury: concussion typically signs are:
altered level of consciousness, amnesia, and headache. Contusion typically signs are: hemorrhage,
infarction, necrosis, edema, seizures, and increased intracranial pressure. But the general manifestation
cause of head injury are: altered level of consciousness, confusion, pupillary abnormalities altered or abset
gag and corneal reflex, sudden onset of neurological onset, changes in vital signs, spasticity, vertigo,
seizures, ottorhoea, rhinorrhea, and slurred speech.

5. Describe the collaborative care and nursing management of the patient with a head injury.
 The collaborative care for patient with a head injury would be to get CT scan to determine craniocerebral
trauma and patient with GCS score less than 15 after head trauma warrants a patient with no intoxicating
consideration of an urgent CT scan. MRI-superior for demonstrating the size of an acute subdural
hematoma. PET, Doppler to look for spasm, cervical spine x-ray to see further injury, GCS. IF the problem
needs for further treatment it may need to undergoes craniotomy, craniectomy, cranioplasty, burr-hole
depending on the seriousness of the injury. Burr-hole is not a surgery itself but an incision, basically a hole
in the skull or cranium to facilitate brain surgeries for the treatment of injuries. The burr hole is used for a
variety of reason such as to make a larger craniotomy which is a surgical procedure in which the bone flap
is removed from the skull to access the brain, or to pass drainage catheters for the evacuation of chronic
blood and cerebrospinal fluid drainage. Traditional method of incision in the skull with the help of a scalpel is
not possible since it is very hard. A saw can be used in its place but it requires special techniques and skill
to avoid any damage to the brain. So a burr hole is recommended to make controlled cuts and not risking
the delicate tissues of the brain. Depressed skull fractures require surgical intervention to debride wound
and remove bone fragments embedded in brain tissue
 Nursing management – nurse action should be to stablish a health history with focus upon the immediate
injury, time, cause, and the direction and force of the blow. Assessment: airway- airway and cervical spine
are immobilized in a neutral position. The nursing actions aimed at maintaining adequate airway clearance
include clearing the mouth and oropharynx of foreign bodies and suctioning the oropharynx and trachea
every 1 to 2 hours and as needed. In addition, positioning to facilitate drainage of oral secretions with head
of bed elevated more than 30 degrees to decrease venous pressure. GCS scoring must be obtained
through interaction with the patient. As the GCS doesn’t affect the completion of the ABG’s, the GCS may
be performed in conjunction with the ABGs, either prior to sedation and paralysis r after the medications are
metabolized. In describing a patient’s state, it is better to use the descriptors rather than GCS score.
Pupillary asymmetry is rarely seen in TBI patient unless the intracranial pressure is greater than 20 mmHg.
Left and right pupillary findings should be identified either unilateral or bilateral dilated pupil. Neurologic
status and presence of CSF leak. Furthermore, maintaining adequate cerebral perfusion– maintaining all
physiologic parameters within normal limits, positioning the patient for optimal venous return, and monitoring
extracerebral system for complications and remain normothermic, prevent secondary cerebral ischemia,
monitor for changes in neurologic status. It requires minimal bed rest and observation of underlying injury.

6. Compare the types, clinical manifestation, and collaborative care of patients with brain tumors.
 A brain tumor is a collection or mass of abnormal cells in brain. Skull which encloses the brain is very rigid
and any growth inside this restricted place can cause problems. When these tumors grow inside the brain it
increases intra cranial pressure, which can cause brain damage and may be even life threatening. Brain
tumor are classified into different parts, however, there are two general groups of brain tumor which is the
primary brain tumor – primary brain tumor starts in the brain tissue and tend to stay there originate within the
CNS and the cause possibly genetics, defective immune system, heredity, viruses, head injury. And
secondary brain tumor – secondary is more common. These cancers start somewhere else in the body and
travel to the brain, lungs, breast, kidney, colon and skin cancer which are among the most common cancers
that can spread to the brain. Also, brain tumor is classified into different grades or stage. Grade 1 – the
cells looks normal and grows slow. Grade 2 – slightly abnormal and also grow slow. Grade 3 – the cells
 looks abnormal and actively growing into nearby brain tissue. Grade 4 – the cells look most abnormal and
grow and spread quickly.
 Clinical manifestation – manifestation depend on tumor size, type and location. Symptoms may be caused
when a tumor presses on the nerve or harms the part of the brain. The most common clinical manifestations
are: headache which usually worse in the morning. Headache is the presenting symptoms during the course
of disease. Nausea and vomiting, papilledema, personality changes like changes in mood, personality or
ability to concentrate, and focal deficits which compose of the motor that causes the problems in balancing
or walking, muscle jerking or twitching which may lead to seizures or convulsions. Sensory that causes
numbness or tingling in the arms or legs, and cranial nerve dysfunctions.
 Collaborative care – Management are determined by histological type, location, grade, and size of tumor,
age of onset, and medical history of the patient. CT scan, MRI, PET Scan, stereotactic biopsy to diagnose
deep-seated brain tumor, cerebral angiography to visualize the cerebral blood vessels because sometimes
tumors are very vascular and they don’t want to cut it out before they get rid of the vessels cause it might
bleed to dead. EEG to detect abnormal brain waves and temporal lobe seizures. Cytologic studies of CSF to
detect malignant cells. And if the tumor is determined treatment may varies. Tran-sphenoidal microsurgical
removal to take the tumor out of the nose. Radiosurgery with a Gamma Knife to deliver dose of radiation.
Steriotactic- a type of procedure to laser or radiation delivery implantation of radioisotopes. Brachytherapy a
surgical implantation of radiation sources. Medical management in preventing complications such as
seizures, stress ulcer, straining, brainstorming, hypermetabolic state, ileus, swallow gag, CSF leak, glucose,
halo, increasing head of bed greater than 30 degrees.

7. Discuss the nursing management of the patient with a brain tumor.

 Nursing intervention will depend on location of tumor and symptoms exhibited. Ongoing neurologic
assessment for changes in mental and functional status; seizure, infection, hemorrhage at the operative site
or within the brain, cerebral edema, and increasing intracranial pressure. Nursing management includes a
baseline neurologic examination and focuses on how the patient is functioning, moving, and walking.
Adapting to weakness or paralysis and loss of vision and speech and dealing with seizures. Assessment
addresses symptoms that cause distress to the patient and affect the quality of life, including pain
respiratory problems, bowel and bladder disorders, sleep disturbances, and impairment of skin integrity,
fluid balance and temperature regulation. A patient with a brain tumor will be in need of monitor for
aspiration, monitor for increase in intracranial pressure, the needs for frequent reorientation to determine if
patient is disoriented, determine or assess the motor function of the patient to have a basis whether the
patient is capable to do ABL’s, assess speech because patient will be having slurred speech, and assess
patient pupillary size and reaction because it may be affected by cranial nerve involvement.
 Patient with a brain tumor may be at increased risk for aspiration as a result of cranial nerve dysfunction.
Preoperatively, the gag reflex and ability to swallow are evaluated. In patients with diminished gag response
care includes teaching the patient to direct food and fluid toward the unaffected side, and having the patient
sit upright to eat, offering a semisoft diet, and having suction readily available. The nurse performs
neurologic checks, monitors vital signs, maintains a neurologic flow chart, spaces nursing interventions to
prevent rapid increase in ICP, and reorients the patient when necessary to person, time and place. Patient
with changes in cognition caused by their lesion require frequent reorientation and the use of orienting
devices, supervision of and assistance with self-care, and ongoing monitoring and intervention for
prevention of injury. Motor function is checked at intervals, because specific motor deficits may occur,
depending on the tumor’s location. Sensory disturbances are assessed. Speech is evaluated. Eye
movement and pupillary size and reaction may be affected by cranial nerve involvement. The psychosocial
effects on family caregivers of a family member who has brain tumor.
 Administer medications to treat cerebral edema with corticosteroids and prevent seizures with
anticonvulsants. Pain management by administering analgesics as ordered and monitor side effects and
encourage and teach relaxation and distraction methods. If mobility is impaired, maintain a safe
environment such as the stairs and rugs when at home and obtain appropriate assistive devices and
 equipment such as cane, walker, wheelchair, commode, bathroom guardrail, shower stool, or safe footwear.
Additionally, if cognition is impaired reorient patient, encourage use of functional ability, provide visual cues
or reminders and encourage social activity. Prevent tissue breakdown by assess the skin pressure point
frequently, assisting with position change, and utilize pressure relief and comfort methods such as
sheepskin, lotion, and massage.

8. Describe the nursing management of the patient undergoing cranial surgery.

 The primary nursing management of the patient undergoing cranial surgery is to prevent increase in the
intracranial pressure. First is for nurse to check for the doctor order on further intervention with the patient
and plan made during the treatment. Frequent assessment of neurological status for the first 24-48 hours to
determine if patient is having neurological deteriorations. Frequent vital signs to determine whether brain is
coping with the body needs. Limiting activities that can increase intracranial pressure. Also, managing the
position of the patient by elevating head of bed no less than 30 – 45 degrees to prevent pressure in the
cranium and the rushing of blood flow in the brain and continuously turning patient every 2 hour. Some
physicians follow a protocol of gradual head elevation, if restrictions, place a sign at HOB. Place patient on
his side to promote airway and facilitate drainage of secretions. Avoid extreme flexion of upper legs or
flexion of neck. Patient undergo cranial surgery will have plenty of drainage attach therefore check drains for
placement, patency and check dressing for drainage, CSF leak. Limiting the suction time to less than 15
seconds to keep patient oxygenated. Furthermore, the needs for continuous medication like anticonvulsant,
corticosteroids, histamine blockers, analgesics, and antibiotics. Medicate with analgesic as ordered such as
morphine and Tylenol.
 For further management patient who undergone cranial surgery, maintaining the airway because obstruction
of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient
may aspirate vomitus or nasopharyngeal secretions. Positioning the patient in a lateral or semi-prone
position also helps, because it allows the jaw and tongue to fall forward, thus promoting drainage of
secretion. Protecting the patient by keeping both side rails raise during the day, and care should be taken to
prevent injury from invasive lines and equipment and other potential sources of injury should be identified,
such as restraints, tight dressings, environmental irritants, damp bedding or dressings, and tubes and
drains. Protection also includes ensuring the patient’s dignity during altered LOC. Simple measures such as
providing privacy and speaking to the patient during nursing care. Maintaining fluid balance and managing
nutritional needs by examining tissue turgor and mucous membranes, assessing intake and output trends
and analyzing laboratory data. Providing mouth care by examining for dryness, inflammation and crusting.
Maintaining skin and joint integrity by frequently assessing during scheduled turning to minimize time spend
with patient. Preserving corneal integrity by cleansing with cotton balls moistened with sterile normal saline
to remove debris and discharges. Maintaining body temperature and preventing urinary retention by
performing palpation on the bladder area. Promoting bowel function by listening for bowel sounds and
measuring the girth of the abdomen with a tape measure. Provide sensory stimulation and meeting the
family needs. Monitoring and managing potential complications such as pneumonia, aspiration, and
respiratory failure. In patient who has a depressed LOC and who cannot protect the airway or turn, cough,
and take deep breaths the longer the period of unconsciousness, the greater the risk is of pulmonary
complication.

9. Differentiate among the primary causes, collaborative car and nursing management of brain abscess, meningitis
and encephalitis.
 Encephalitis is an acute inflammation of the brain, sometimes fatal, primarily cause by a number of viruses
and ticks or mosquitoes that transmits epidemic encephalitis. Primary cause of meningitis is also classified
as Bacterial and Viral. Bacterial is the gain access through bloodstream, wounds of the skull, and fractures
to the skill or sinuses. Once the causative organism enters the bloodstream, it crosses the blood brain
barrier and proliferates in the cerebrospinal fluid. The host immune response stimulates the release of cell
wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. The
prognosis for bacterial meningitis depends on the causative organism, the severity of the infection and
 illness and the timeliness of treatment. Viral is secondary to lymphoma, leukemia or HIV. Brain abscess is
the accumulation of pus within brain tissue caused by Streptococci and Staphylococcus aureus and it is a
sign of increased in ICP. A brain abscess is a collection of infectious material within the tissue of the brain.
An abscess can result from intracranial surgery, penetrating head injury, or tongue piercing. Organisms
causing brain abscess may reach the brain by hematologic spread from the lungs, gums, tongue, or heart,
or from a wound or intra-abdominal infection.
 Collaborative care – directed prescriptive antibiotic therapy in the basis as ordered by the providers, oxygen
for hypoxemia – providing oxygen to nourish the blood in the brain, antipyretics for preventing further
complications, increase fluid intake at least 3 L per day maintaining the hydration organs in the brain, and
caloric intake at least 1500 per day. Diagnostic test – blood cultures to determine any other infection in
blood and in the system, lumbar puncture and analysis of CSF for grain stained smear to detect bacteria, X-
rays of skull to determine for increase intracranial pressure, CT scan for further evaluation of any possible
problem in the brain, PET, MRI, and PCR test for HSV DNA/RNA.
 Nursing management- Meningitis - observe record seizures, administer anti-seizures medications, manage
fever, frequent assessment for dehydration, initial respiratory isolation, progressive ROM exercise, and
increase activity as tolerated. Protecting the patient from injury secondary to seizure activity or altered LOC
and monitoring daily body weight, serum electrolytes and urine volume, specific gravity and osmolality,
especially if syndrome of inappropriate antidiuretic hormone SIADH is suspected. Preventing complications
associated with immobility such as pressure ulcers and pneumonia. Additionally, Instituting infection control
precautions until 24 hours after initiation of antibiotic therapy. Encephalitis – Mosquito control for prevention,
antibiotic: Acyclovir, Vidarabine for HSV infection, anti-seizure drugs and palliative care. Brain Abscess –
assess for signs of confusion, seizures, fever, headache, nausea and vomiting, and symptoms reflect local
area of abscess. Nursing care focuses on continuing to assess the neurologic status, administering
medications, assessing the response to treatment, and providing supportive care. The nurse will need to
assess and document the responses to medications. Administration of insulin or electrolyte replacement
may be required

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